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1. (CPT billing codes 99605, 99606, and 99607)
ANS Medication Therapy Manage- ment (MTM)
2. (CPT billing codes 99211-99215)
ANS Incident-to
3. (CPT codes 99496 and 99495)
ANS Transitional care management (TCM)
4. (CPT codes G0438 and G0439)
ANS CMS annual wellness visit (AWV)
5. (CPT codes 99490)
ANS Incident-to physician Chronic care management
6. (CPT codes 99487 and 99489)I
ANS ncident-to physician Complex chronic care management
7. (CPT codes G0108 and G0109)
ANS Diabetes self-management training
8. (CPT codes 98960, 98961, and 98962)
ANS Diabetes education
9. (APC code 5012 with HCPCS code G0463)
ANS Office visit in a hospital-based clinic (Hospital outpatient)
10. (CPT codes 99211-99215)
ANS The majority of options for pharmacist revenue generation are through the Evaluation and Management (E&M)
11. Prior Authorization
ANS the need to obtain permission from the insurance com- pany before seeking certain types of services
12. There are several kinds of medications that may require prior authoriza- tion
ANS
1- A brand name medication that is available as a generic
2- An expensive medication
3- A medication used for cosmetic reasons (such as those for hair growth and
wrinkle treatment)
4- A medication prescribed at higher doses than normal 5- A
medication that treats non-life threatening conditions 6- A medication not usually covered by the insurance company, but deemed medically necessary by the physician
13. Steps for Prior Authorization
ANS
Step 1 The pharmacy contacts the physician who prescribed the medication to see if he or she obtained prior authorization from the insurance company when the drug was prescribed. Step 2
insurance card or insurance company and then edit the claim before resubmitting. You may need to contact the insurance company to get more information on the problem.
2- No Group Number on the claim. To fix the problem, you must find the patient's
group number on the insurance card, fix the error, and resubmit the claim.
3- No NPI (National Provider Identifier) or invalid NPI on the claim. The pharmacist
must have a contract with the payer. Once the contract is negotiated, the payer will provide an NPI number. This number is then inputted into the pharmacy software and included on all claims.
4- No Cardholder ID Number or invalid Cardholder ID number on the claim. To fix
this, you must find the correct Cardholder ID number and resubmit the claim.
5- Plan Limitations Exceeded. If the claim submitted needs prior approval before
coverage because of the medication expense, it may be rejected. Additionally, if the medication was already filled in the last 30 days or the quantity dispensed is over the allowed amount for the day supply, the claim may be rejected. To fix these issues, you will need to contact the insurance company to obtain an override or approval on the cost before resubmitting the claim.
6- Waiting Too Long to File the Claim. Most insurance companies allow 60 to 90 days
from time of service to file a claim. When claims are filed past that time, the claim may be rejected.
7- Incorrect Patient Information. Any error in patient information will trigger a claim
rejection. Common errors include incorrect name, days supply, provider, date of birth, etc.
8- Coverage has expired. If the patient does not pay premiums or no longer works at
employer-provided insurance, the patient's coverage may not be current.
10-Coverage limits have been exceeded. The insurance plan may have a limit on the
amount of coverage they provide for each patient annually or for a lifetime. The claim may be rejected if the coverage limits have been exceeded.
11-Refills. In some cases, the patient may be trying to get a prescription refilled
when it either is not refillable or within too short of a time frame. The insurance payer may reject this claim.
12-Invalid Amount. The prescription may be written for an invalid amount of the
medication. Most insurance companies cover only a 30-day supply of medication. Mail- order prescriptions may cover a 90-day supply. The amount depends on the actual drug.
15. Coordination of Benefits (COB)
ANS is the process in which two or more health insurers cover the same person(s) but limit the total benefit payable for a claim to an amount not exceeding the total cost of the claim. Coordination of Benefits applies to retail pharmacy claims, member- submitted paper claims, and mail-order claims.
If the court decree states that the parents have joint custody without specifying that one parent has healthcare coverage responsibility, the Birthday Rule determines the ordre of benefits. If there is no court decree allocating healthcare coverage responsibility for the child, the order of benefits for the child is as follows ANS a. the plan covering the custodial parent; b. the plan covering the custodial parent's spouse; c. the plan covering non-custodial parent; and then, d. the plan covering the noncustodial parent's spouse
18. hood suould be operated?
ANS 24 hours in hospitals pharmacy and at least 30 min prior to use in comunity pharmacy.
19. what reasonable working distance from the Hood?
ANS work should be at least 6 inches into the hood.
20. sterile instruments should be held under?
ANS Class 100 (ISO 5)
21. The federal food and drug act (1906)
ANS prohibited instersate commerce and adulterated and misbranded drugs.
22. Fedral Food Drugs and Cosmetics Act ( FDCA1938)
ANS Established the FDA (stated the drugs cannot brought on the market untill proved to be safe), clarified the definition of misbranding and adulteration.
23. Durham-Humphrey Amendment (1951)
ANS It requires the drug prove to be safe and print instructions clearly on the manufacture label. Created new legend drug what's known as prescription drug. And created warning (Caution Federal law prohibits dispensing without prescription) Currently the requirement has been changed in shorter warning (Rx only).
24. The Kefauver-Harris Amendment (1962)
ANS This law requres for the first time a proof of the effectiveness of the drug as well as its safety.
25. The food and administration modernization act (1997)
ANS This act simplifies many FSA regulations and procedures. It allows greater ease and speed with the FDA can approve a new drug and granted access to investigational medication. It's also abbreviated the warning to Rx Only
26. The Drug Addiction Treatment Act (2000)
ANS This act permitted physician who completed a training course and who registers with the DEA to prescribe approved C-III, C-IV, C-V medication.
27. The Medicaire Modernization Act (2003)
ANS Allow medicaire benificiaries to enroll in medicaire advantage, or medicaire part D (coverage for prescription drug).
34. The Drug Abuse Control Amendment (DACA) (1965)
ANS Expands Harrison Act to include barbiturates and stimulant drugs
35. The Bureau of Narcotics and Dangerous Drugs (1968)
ANS The Harrison Act and DACA were combined under newly formed Bureau of Narcotics and Dan- gerous Drugs. in 1973, the Bureau was renamed to the DEA (Drug Enforcement Administration).
36. The Comprehension Drug Abuse Prevention and Control Act (1970)
ANS - Known as Controlled Substances Act (CSA). Replaced the Harrison and DACA and established the concept of the DEA number originated with the CSA.
37. The Poison Prevention Packaging Act (PPPA) (1970)
ANS Requires locking cap on all prescriptions dispensed from pharmacy with only 3 exceptions.
1) when patient asks for non-safety lid
2) when prescriber asks for non-safety lid
3) when the drug dispensed is an exempted drug (sublingual nitroglycerin).
Also required all the prescriptions bottles to be child proof.
38. The OBRA Law (1990) (Omnibus Budget Reconcildation Act)
ANS 1) Retro- spective Drug Utilization Review (DUR)
2) Prospective Drug Utilization Review
3) Mandates councilling to medicaid patient (many states extend councelling to all
patients)
39. JCAHO (Joint Commission on Accreditation of Healthcare Organiza- tions)
ANS Non-government organization conduct voluntary certification and inspec- tion on 20,000+ healthcare organizations including Hospital, Nursing Homes, long term care facilites, Ambulatory care providors, and clinical laboratories
40. Patient Package Insert (Monographs)
ANS 1) Regulated by FDA
2) PPI (Monograph) must include
A) indication
B) Contradiction
C) Warning
D) Precaution
E) Dose and Route of administration
41. Occupational Safety and Health Administration (OSHA) (1970)
ANS 1) Ensures safe workplace for employee by reducing hazards in workplace
2) Ensures job safety standard and requires reporting of any job related injuries or
illness
3) Requires Material Safety data sheet (MSDS) for any hazardous material
Health consequences are reversible Class 3 Not likely to cause adverse health consequences (physically adulterated drug or mislabelling drugs)
45. The New Drug Application Process (NDA Process)
ANS Phase I - Trial involves small # of volunteers to determine maximum tolerated dose of applicant drug (toxicity) Phase II - Primarily concerned with (effectiveness) Phase III - Last trial before NDA submitted to FDA. "Double Blind" method with thousands of individuals. Phase IV - takes place after NDA submits to FDA. Allows manufactures to produce drugs
46. National Drug Code (NDC)
ANS Each drug produced by a manufacturer is iden- tified with a specific NDC number. The NDC number is composed of three sets of numbers, which identifies the manufacturer, drug, and pack size. The first 5 numbers represent the manufacturer. the second 4 numbers represent the drug. The last/third 2 numbers represent the packaging size. 00000-0000-
47. DEA number formula
ANS (1st + 3rd + 5th) + 2 (2nd + 4th + 6th) = last digit is last digit of DEA #. Usually the first letter is
A or B for physician, provider F or P for manufacturer M for mid-level provider The 2nd letter represents the last name of the provider AG
48. DEA Forms
ANS 222 - to order CII's 224 - to register with the DEA - check box to get 222 forms with registration 106 - to report theft or loss to the DEA 41 - to report drugs surrendered for disposal 104 - pharmacist surrender his/her license
49. Controlled Substances Act of 1970
ANS classifies controlled substances accord- ing to their abuse potentials. Schedule II = Prescription can be handwritten or computer generated but must be signed in ink by physician (no allowable refill) Schedule III-V = Prescription can be handwritten or computer generated must be signed by physician in ink the office may telephone or fax prescription. Paitent may receive up to 5 refills within 6 months.
ANS 1 oz = 28.4 g
57. qt to mL
ANS 1 qt = 946 mL
58. qt to pt
ANS 1 qt = 2 pt
59. Calculating active ingredient
ANS 1w/v1000 = (g of active ingredient/mL of active ingredient)
60. Code 1 for insurance billing
ANS Insured
61. Code 2 for insurance billing
ANS Spouse
62. Code 3 for insurance billing
ANS Dependent
63. rejection code 19
ANS Day supplied missing or not valid
64. Rejection code 11
ANS Relationship code invalid or missing
65. Rejection code 9
ANS When date of birth invalid or missing
66. Rejection code 04
ANS Processor Control Number (PCN)
ANS Ampul require the suse of filter needle to remove very samll particles of glass that may have fallen into the liquid when the ampule was broken.
77. used to prepare chemorheraputic agents
ANS vertical laminar flow hood accord- ing to USP <797>
78. According to USP 797, what should not be worn during compounding?-
ANS prohibts artificial nails , cosmatics, and jewlery
79. what type of blance can be used to weigh up to 5 kg?
ANS counter balance
80. who is responsible to transport hazardous material?
ANS DOT , department of Transportaion
81. which is not required on IV admixture labeling?
ANS physician name not re- quired on label , but beyond -use date, deip rate and ingredients are required on the IV label.
82. What type of balance must a pharmacy have?
ANS Class A
83. How often does the pharmacy balnce need to be certified?
ANS every 12 months , according to USP<795>
84. what type of environmental classification should laminar floww hood
provide ANS ISO 5 (formaly class 100 area)
85. what is the name of the opening of the needel?
ANS lumen
86. what is the sensitivity of a class A balance
