2024 Self-Audit Series #5: Topical Prescriptions

Topical medications are easy audit targets, especially with the rising costs of some of these medications. The discrepancy that is commonly cited for topical medications is …

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“non-calculable instructions”. This means the PBM does not feel the pharmacy can accurately bill the days’ supply based off the instructions on the prescription. This will require pharmacies to obtain additional information, usually in a prescriber’s statement, in an attempt to appeal.

Pharmacies must do their due diligence to ensure the appropriateness of what is being billed. Prescriptions that include the number of grams per application and a frequency can easily be billed with an accurate days’ supply. Vague instructions for use should be clarified with the prescriber and documented with a clinical notation on both the prescription and added to the patient’s label (an OptumRx requirement!).

Pharmacies must not rely on the days’ supply field indicated on an electric prescription as this is not accepted by PBM auditors. Prescriptions written for a quantity of “1”, are generally flagged for “incomplete quantity”. Auditors require a specific quantity in grams, milliliters, or pumps to be indicated. Verifying and documenting can help avoid audit recoupments!

PAAS Tips:

  • Educate staff to review topical prescriptions for complete instructions prior to filling
  • Self-audit expensive topical prescriptions frequently to ensure the instructions are sufficient for audit
  • Download and share with staff, the PAAS National® Topical Creams and Ointments Chart and utilize the PAAS National® App when utilizing the Finger-Tip Unit method
    • See PAASNational.com/app for more information
  • Topical medications should only be filled upon request
  • Reminder that all clinical notations should include: date, name and title of who you spoke with, what was clarified, and your initials

Dana Westberg, CPhT
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