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Compound Pharmacy Claim Form (30-4) Examples (compound ex)

By Don Bradley,2014-04-13 21:44
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Compound Pharmacy Claim Form (30-4) Examples (compound ex)

     compound ex

    Compound Pharmacy Claim Form (30-4) Examples 1

The examples in this section are to assist providers in billing on the Compound Pharmacy Claim Form

    (30-4). Refer to the Compound Pharmacy Claim Form (30-4) Completion section of this manual for

    instructions to complete claim fields not explained in the following examples. For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section of this manual.

    Billing Tips: Quantities must be in the metric decimal system if the quantity is not a whole number.

     Do not round the quantity. For example, a quantity of 3.5 Gm should be expressed as

    3.500, rather than rounding to 4. Do not include measurement units such as Gm or cc.

    The Compound Pharmacy Claim Form (30-4) has separate fields for the whole number

    and decimal portions of the quantity fields. Decimals points are not allowed within the

    fields. The decimal points are pre-imprinted on the form. All information on an

     attachment must match the information entered on the claim form.

2 Compound Pharmacy Claim Form (30-4) Examples Pharmacy 572 December 2003

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Compounded Prescription Figure 1. Compounded intravenous prescription.

     This is a sample only. Please adapt to your billing situation.

     In this example, a pharmacist is billing for a compounded intravenous

    prescription. The date of service is the date that the prescription was

     filled. The date is entered in an eight-digit MMDDYYYY (Month, Day,

     Year) format in the Date of Service field (Box 11). In this example,

     November 2, 2003 is entered as “11022003.”

     The provider estimates the dispensed drug will last four days. Since

    the compound is a solution, “11” is entered in the Dosage Form

    Description field (Box 21). A “3” is entered in the Dispensing Unit

    Form Indicator field (Box 22) to indicate the unit of measure of the

    compound is milliliters (or cc). The compound is to be administered

    to

     the patient intravenously, so “04” (used for injections, including

     intravenous and interarterial) is entered in the Route of Administration

    field (Box 23).

     The type of product IDs being submitted on the ingredient lines are

    National Drug Code (NDC), so “03” is entered in the Product ID

    Qualifier field (Box 30). Each Ingredient Quantity field (Box 32) is the

    sum of the amount of that ingredient that is in all containers of the

    compound. The Ingredient Charge (Box 33) should reflect the total

    charge for the ingredient in all containers of the compound. The

    method used to calculate ingredient cost is not specified, which is

    indicated by nothing being entered in the Basis of Cost field (Box 34).

     The sum of all the ingredient charges should be entered in the

    Ingredient Total Charge field (Box 39). Do not include fees in this

    number. In this example, Process for Approved Ingredients field

    (Box 40) is left blank. If a “Y” was in Process for Approved

    Ingredients it would mean that if any ingredients having National Drug

    Codes (NDCs) are not found in the List of Contract Drugs or if any

    ingredients require a Treatment Authorization Request (TAR) and no

    TAR is present, those ingredients will be priced at zero and the

    remainder of the ingredients will be paid. When Process for

    Approved Ingredients is “Y,” the provider knows that a portion of the

    ingredients may not be paid and accepts payment for the remainder,

    rather than

     having the entire claim denied. This could be useful if the provider

     has a claim with inexpensive ingredients that require a TAR. It might

     be more cost-effective to do without the payment for the inexpensive

    items than to apply for prior authorization for those items.

     This compound is distributed among four containers, so a “4” is

    entered in the Container Count field (Box 41).

2 Compound Pharmacy Claim Form (30-4) Examples Pharmacy 572 December 2003

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    Figure 1. Compounded Intravenous Prescription. 2 Compound Pharmacy Claim Form (30-4) Examples Pharmacy 691 November 2008

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    Compounded Prescription Figure 2. Compounded prescription with more than 25 ingredients. With More Than 25 Ingredients This is a sample only. Please adapt to your billing situation.

     In rare instances, it may be necessary to bill for compounds with more

    than 25 ingredients. Since the Compound Pharmacy Claim Form

    (30-4) can only hold 25 ingredients, the first 24 ingredients should be thentered into the claim form. The 25 ingredient should have a

    Product ID Qualifier of “99” and a Product ID of “99999999998.” The thquantity of the 25 ingredient should be the sum of the remaining

    ingredients not listed on the claim form. The ingredient charge for the th25 ingredient should be the sum of the remaining ingredient charges.

     Figure 3. Compounded Drug attachment

     This is a sample only. Please adapt to your billing situation.

     The ingredients not listed on the 30-4 claim form should be included

    in an attachment showing (NDC/UPC/HRI#), Product ID, Quantity,

    Charge and Basis of Cost (Description) for each.

2 Compound Pharmacy Claim Form (30-4) Examples Pharmacy 566 September 2003

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    Figure 2. Sample Compounded Drug With More Than 25 Ingredients 2 Compound Pharmacy Claim Form (30-4) Examples Pharmacy 691 November 2008

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    Compounded Drug Attachment

Pharmacy Name: ABC Home Pharmacy

    Provider Number: 0123456789

    Prescription Number: 1234567

    Date of Service: 03/02/2007

Additional Compound Ingredients:

NDC/UPC/HRI # Quantity Charge Description

    61703022521 360.00 3386.70 00517240025 300.00 18.41

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    Totals 660.000 3405.11 2 Compounded Drug Attachment Completion PROPubs Draft Date: 10/29/2008

    Figure 3. Sample Compounded Drug Attachment.

    2 Compound Pharmacy Claim Form (30-4) Examples Pharmacy 691 November 2008

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