Discuss the legal requirements for pharmaceutical reimbursement in terms of the application of the National Drug Code (NDC) to the coding and billing function in the following scenario.

 

 While reviewing a rejected claim as a clinical documentation analyst, you noticed that a hysterectomy on a patient was recorded in the medication reconciliation section of the EHR as hysteroscopy. After comparing the two, you noticed that hysteroscopy costs way less than the actual procedure done on the patient. Upon further digging, you discovered that the error had happened repeatedly during the same year. You also found that hysterectomy is just one step up from hysteroscopy on the drop-down box in the medication reconciliation section in the EHR.

Pharmaceutical reimbursement is legally required to use the National Drug Code (NDC) to ensure that the correct drug is being billed for. The NDC is a unique identifier for each drug that is assigned by the Food and Drug Administration. This code is used to track the drug and ensure that it is billed correctly.
 

Step-by-step explanation

• Pharmaceutical reimbursement is the process by which a healthcare organization is reimbursed by a third-party payer for the costs of providing pharmaceutical products and services. This process is critical to the financial stability of healthcare organizations, as it allows them to be reimbursed for the significant costs associated with providing medications. There are a number of factors that contribute to the reimbursement process, including the use of the National Drug Code (NDC) to ensure that the correct drug is being billed.
• The NDC is a distinguished identifier for each drug that is assigned by the Food and Drug Administration (FDA). This code is used to track the drug and ensure that it is billed correctly. The use of the NDC is mandatory for pharmaceutical reimbursement, as it allows payers to ensure that they are only paying for the products and services that they are responsible for. This code is also beneficial to healthcare providers, as it helps them to identify and track the products that they are providing to their patients.
• In addition to the use of the NDC, there are a number of other factors that contribute to the reimbursement process. One of these factors is the coding and billing function within the healthcare organization. This function is responsible for accurately capturing the services that are provided to patients and submitting these claims to the appropriate payers. It is critical that this function operates efficiently and accurately, as any mistakes can lead to delays in reimbursement or even denials of claims.
• Another factor that contributes to the reimbursement process is the relationship between the healthcare organization and the payer. This relationship is important, as it helps to ensure that the payer is aware of the products and services that the healthcare organization is providing. It also allows the payer to establish rates for reimbursement that are fair and equitable for both parties.
• The reimbursement process is critical to the financial stability of healthcare organizations. By accurately capturing the services that are provided to patients and submitting these claims to the appropriate payers, healthcare organizations can be reimbursed for the significant costs associated with providing medications. The use of the National Drug Code is essential to this process, as it allows payers to ensure that they are only paying for the products and services that they are responsible for. This code is also beneficial to healthcare providers, as it helps them to identify and track the products that they are providing to their patients.