PC codes and billing information For DOS Before September 1, 2012

Reason for Service Code — DefinitionProfessional Service Code — DefinitionResult of Service Code — DefinitionLevel of Effort and FeeFee Limits and NotesDocumentation Requirements
AD (60) — Based on review of the member's drug regimen, the pharmacist determined treatment may be enhanced by addition of a new drug to the existing drug regimen. M0 (22) — Prescriber contacted. 1E (14) — Order filled with different drug. Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two AD (60) PC dispensing fees per member, per year.

Level 13 = maximum PC dispensing fee
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Nature of problem that additional drug may correct.
  • Summary of and basis for recommendation(s).
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
AN (10) — Prescription order forgery suspected. M0 (22) — Prescriber contacted.

R0 (29) — Pharmacist contacted other source or contact (e.g., police or another pharmacy).

TC (15) — Payer/processor contacted.

To submit Action code R0, prescriber must be contacted and concur that the prescription order should not be filled.		 2A (30) — Order not filled. Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 Prescriber contact required for PC dispensing fee.

A maximum of two AN (10) PC dispensing fees per member, per year.

Level 14 = maximum PC dispensing fee.

Not billable for nursing home residents.
  • Date of intervention.
  • List prescription orders questioned. Include drug, quantity, directions, and prescriber name.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Basis for suspicion of forgery.
  • Summary of any communication with prescriber, member, or other contact.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
AR (61) — Based on information obtained about the member's medical condition, the pharmacist has determined the member may be experiencing an adverse drug reaction. M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two AR (61) PC dispensing fees per member, per year.

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

Not billable for nursing home residents.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Nature of adverse reaction.
  • Identify drug(s) involved.
  • Summary of and therapeutic basis for recommendation(s).
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
AT (40) — Member's drug regimen includes multiple drugs that may cause additive toxicity or side effects according to medical literature. M0 (22) — Prescriber contacted.

RT (30) — Pharmacist recommended lab test to the physician.		 1C (12) — Order filled with a different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with a different drug.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with a different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two AT (40) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Nature of problem caused by multiple drugs.
  • Identify drugs.
  • Summary of and basis for recommendation(s).
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
CD (71) — New diagnosis or new drug therapy — ASTHMA. The pharmacist has determined that additional education or counseling is necessary. M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 A maximum of six CD (71) PC dispensing fees per member, per year.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Verify new diagnosis.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify new drug therapy.
  • Summary of information or education provided in each session.
  • Prepare and maintain a therapeutic work-up and report to be made available to the prescriber on request.
  • Pharmacist helped the member understand all member-specific, drug-related problems.
  • Desired therapeutic outcome(s) expected.
  • Plan for monitoring the member.
  • Pharmacist's name.
PE (25) — Verbal or written communication to the member by a pharmacist to enhance the member's knowledge about the condition under treatment, or to develop skills and competencies related to its management. 3K (85) — Member understands.

3M (80) — Compliance aid developed.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 A maximum of six CD (71) PC dispensing fees per member, per year.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Verify new diagnosis.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify new drug therapy.
  • Summary of information or education provided in each session.
  • Prepare and maintain a therapeutic work-up and report to be made available to the prescriber on request.
  • Pharmacist helped the member understand all member-specific, drug-related problems.
  • Desired therapeutic outcome(s) expected.
  • Plan for monitoring the member.
  • Pharmacist's name.
CS (63) — Based on member complaint or known or suspected symptom(s), the pharmacist initiated drug regimen review or member consultation. The pharmacist determined an actual or potential medical problem, other than adverse drug reaction, may exist. AS (20) — Evaluation of information known by the pharmacist or supplied by the member for the purpose of developing a problem-based therapeutic plan. 3K (85) — Instructions understood. Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of one CS (63) PC dispensing fee per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.

Note: Rule out use of other PC reason codes which may be more specific to the problem before using this code.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Member complaints or symptom(s).
  • Process, including medical literature, used to determine actual or potential problem.
  • Description of therapeutic basis for the possible problem.
  • Summary of outcome, including summary of any communication, with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of one CS (63) PC dispensing fee per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.

Note: Rule out use of other PC reason codes which may be more specific to the problem before using this code.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Member complaints or symptom(s).
  • Process, including medical literature, used to determine actual or potential problem.
  • Description of therapeutic basis for the possible problem.
  • Summary of outcome, including summary of any communication, with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
DA (41) — Member has a known or suspected allergy to this drug or drug with similar pharmacological effects resulted in atypical reactions. M0 (22) — Prescriber contacted. 1E (14) — Order filled with different drug.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two DA (41) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Nature of allergy problem.
  • Identify drug.
  • Summary of and basis for recommendation(s).
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
DD (44) — Member's drug regimen includes multiple drugs which may result in unintended pharmacological response according to medical literature. M0 (22) — Prescriber contacted. 1C (12) — Order filled with a different dose.

1E (14) — Order filled with different drug.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two DD (44) PC dispensing fees per member, per year.

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug(s).
  • Nature of problem caused by multiple drugs.
  • Summary of and basis for recommendation(s).
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
DI (45) — IV drug incompatibility detected. M0 (22) — Prescriber contacted. 1E (14) — Order filled with different drug.

2A (30) — Order not filled.

 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two DI (45) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Nature of compatibility problem.
  • Summary of and basis for recommendation(s).
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
DM (65) — Possible drug misuse. M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.

3K (85) — Member demonstrates understanding of proper medication use.

3M (80) — Compliance aid developed.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 A maximum of two DM (65) PC dispensing fees per member, per year.

Not billable for nursing home residents.

Note: Rule out use of other PC reason codes which may be more specific to the problem before using this code.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Description of possible problem.
  • Summary of outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
ER (20) — Early refill.
— Compliance problem suspected.
— Refill before 80 percent of previous prescription should be consumed, based on predicted days' supply (abuse not suspected).
— Do not use this code if abuse is suspected or documented. See Reason code DM (65).		 M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.

3K (85) — Member demonstrates understanding of proper medication use.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of four ER (20) PC dispensing fees per member, per year.

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

A PC dispensing fee may not be claimed under this code if the early refill is determined to be due to something other than a compliance problem (e.g., member leaving town, early refill for convenience, lost medication).

Maximum PC dispensing fee: Level 13 on professional service code M0 and level 13 on professional service code PE.

Not billable for nursing facility residents.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Dates for previous two refills.
  • Expected date for this refill.
  • Number of days early, percent early on days supply.
  • Determined reason for early refill request.
  • Outcome, including summary of any communication with prescriber and member.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
PE (25) — Verbal or written communication to the member by a pharmacist to enhance the member's knowledge, skills, and competencies. 2A (30) — Order not filled. Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of four ER (20) PC dispensing fees per member, per year.

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

A PC dispensing fee may not be claimed under this code if the early refill is determined to be due to something other than a compliance problem (e.g., member leaving town, early refill for convenience, lost medication).

Maximum PC dispensing fee: Level 13 on professional service code M0 and level 13 on professional service code PE.

Not billable for nursing facility residents.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Dates for previous two refills.
  • Expected date for this refill.
  • Number of days early, percent early on days supply.
  • Determined reason for early refill request.
  • Outcome, including summary of any communication with prescriber and member.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
3K (85) — Member demonstrates understanding of proper medication use.

3M (80) — Compliance aid developed.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $14.68
14 — $14.68
15 — $14.68		 A maximum of four ER (20) PC dispensing fees per member, per year.

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

A PC dispensing fee may not be claimed under this code if the early refill is determined to be due to something other than a compliance problem (e.g., member leaving town, early refill for convenience, lost medication).

Maximum PC dispensing fee: Level 12 on professional service code M0 and level 12 on professional service code PE.

Not billable for nursing facility residents.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Dates for previous two refills.
  • Expected date for this refill.
  • Number of days early, percent early on days supply.
  • Determined reason for early refill request.
  • Outcome, including summary of any communication with prescriber and member.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
EX (21) — Prescribed quantity appears excessive for the member's condition or predicted medical need according to medical literature (abuse not suspected). M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

ID (13) — Order filled with different directions.

1E (14) — Filled, different drug.

1F (15) — Order filled with different quantity.

1K (18) — Filled, dose form change.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 Prescriber contact required.

A maximum of two EX (21) PC dispensing fees per member, per year.

Do not use this code if abuse is suspected or documented. See Reason Code DM (65).

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.

Note: Titration or other dose adjustment must first be ruled out.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes)
  • Identify drug.
  • Expected quantity for member's condition.
  • Determined reason for prescribed quantity.
  • Outcome including summary of any communication with prescriber and member.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
HD (23) — Prescribed dose is above the standard range for member's condition according to the literature (abuse not suspected). M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two HD (23) PC dispensing fees per member, per year.

Do not use this code if abuse is suspected or documented. See Reason code DM (65).

Result code 2A (30) may only be used when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
LD (33) — Prescribed dose may be insufficient to treat this member's medical condition according to medical literature.
— Titration ruled out.		 M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two LD (33) PC dispensing fees per member, per year.

An LD (33) PC dispensing fee may not be claimed if titration is determined to be the basis for the "insufficient" dose.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Minimum expected dose.
  • Source of minimum recommendation.
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
LK (66) — Member has been selected to be locked in to a physician and/or pharmacist based on information known about the member's medical condition and use of excessive medication in a manner that may indicate drug abuse or diversion. CC (21) — Pharmacist initiated contact with multiple prescribers to facilitate coordination of care.

M0 (22) — Prescriber contacted.		 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.

3K (85) — Instructions understood.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 A maximum of 15 LK (66) PC dispensing fees per member, per year.

An LK (66) PC dispensing fee is indicated when lock-in pharmacy manages members enrolled in the Pharmacy Services Lock-In Program.

Not billable for nursing home residents.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Description of possible problem.
  • Name of person(s) contacted.
  • Summary of outcome, including summary of any communication with prescriber(s), patient, and other contact(s).
  • Indicate if intervention was for safety, efficacy, compliance or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
PE (25) — Verbal or written communication with patient by a pharmacist to instruct patient in appropriate drug use.

TC (15) — Pharmacist communicated with claims processor or state Medicaid program staff.		 2A (30) — Order not filled.

3K (85) — Instructions understood.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 A maximum of 15 LK (66) PC dispensing fees per member, per year.

An LK (66) PC dispensing fee is indicated when lock-in pharmacy manages members enrolled in the Pharmacy Services Lock-In Program.

Not billable for nursing home residents.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Description of possible problem.
  • Name of person(s) contacted.
  • Summary of outcome, including summary of any communication with prescriber(s), patient, and other contact(s).
  • Indicate if intervention was for safety, efficacy, compliance or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
LR (25) — Late refill requested.
— Compliance problem suspected.
— More than 25 percent after member should exhaust previously dispensed medication based on predicted days' supply.		 M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with different drug.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of four LR (25) PC dispensing fees per member, per year.

A PC dispensing fee may not be claimed under this code when the late refill is determined to be due to something other than a compliance problem (e.g., member had last refill filled elsewhere, previous early refill for convenience, previous lost refill found).

Do not use this code if abuse is suspected or documented. See Reason code DM (65).

Not billable for nursing home residents.

Level 13 = maximum PC dispensing fee.

Maximum PC dispensing fee: Level 13 on professional service code M0 and level 12 on professional service code PE.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Dates for previous two refills.
  • Expected date for this refill.
  • Number of days late; percent late on days supply.
  • Determined reason for late refill.
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
PE (25) — Verbal or written communication to the member by a pharmacist to enhance the member's knowledge, skills, and competencies. 3K (85) —Member demonstrates understanding of proper medication use.

3M (80) — Compliance aid developed.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $14.68
14 — $14.68
15 — $14.68		 A maximum of four LR (25) PC dispensing fees per member, per year.

A PC dispensing fee may not be claimed under this code when the late refill is determined to be due to something other than a compliance problem (e.g., member had last refill filled elsewhere, previous early refill for convenience, previous lost refill found).

Do not use this code if abuse is suspected or documented. See Reason code DM (65).

Not billable for nursing home residents.

Level 12 = maximum PC dispensing fee.

Maximum PC dispensing fee: Level 13 on professional service code M0 and level 12 on professional service code PE.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Dates for previous two refills.
  • Expected date for this refill.
  • Number of days late; percent late on days supply.
  • Determined reason for late refill.
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
MN (30) — Prescribed length of therapy may be shorter than minimum period recommended in medical literature for this member's condition.
— Titration ruled out.		 M0 (22) — Prescriber contacted. 1D (13) — Order filled with different directions.

1F (15) — Order filled with different quantity.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two MN (30) PC dispensing fees per member, per year.

An MN (30) PC dispensing fee may not be claimed if titration is determined to be the basis for the short length of therapy.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Minimum expected length of therapy.
  • Source of minimum recommendation.
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
MX (22) — Prescribed length of therapy exceeds expected length of therapy for this member's condition according to medical literature (abuse not suspected). M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with a different drug.

1F (15) — Order filled with different quantity.

1K (18) — Order filled with a different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 Prescriber contact required.

A maximum of 2 MX (22) PC dispensing fees per member, per year.

Do not use this code if abuse is suspected or documented. See Reason Code DM (65).

Result Code 2A (30) can only be indicated when a replacement drug is not prescribed.

Not billable for nursing home residents.

Level 13 = maximum PC dispensing fee.

Note: Titration or other dose adjustment must first be ruled out.
  • Date of intervention.
  • Professional time spent on intervention (minutes).
  • Time spent on documentation (minutes).
  • Identify drug.
  • Expected length of therapy.
  • Determined reason for prescribed length of therapy.
  • Outcome including summary of any communication with prescriber and member.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
NN (80) — The pharmacist determined continued therapy using a prescribed drug may not be necessary. M0 (22) — Prescriber contacted. 2A (30) — Order not filled. Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.16
15 — $40.16		 A maximum of two Reason NN (80) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Not billable for nursing home residents.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Summary of issue and therapeutic basis for recommendation.
  • Summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • List of discontinued drugs, if any.
  • Pharmacist's name.
NS (32) — Prescribed quantity may be insufficient to treat this member's medical condition adequately according to medical literature.
— Titration ruled out.		 M0 (22) — Prescriber contacted. 1D (13) — Order filled with different directions.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two NS (32) PC dispensing fees per member, per year.

An NS (32) PC dispensing fee may not be claimed if titration is determined to be the basis for the "insufficient" quantity.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Minimum expected quantity.
  • Source of minimum recommendation.
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
1F (15) — Order filled with different quantity. Level — Fee
11 — $9.45
12 — $9.45
13 — $9.45
14 — $9.45
15 — $9.45		 A maximum of two NS (32) PC dispensing fees per member, per year.

An NS (32) PC dispensing fee may not be claimed if titration is determined to be the basis for the "insufficient" quantity.

Level 11 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drug.
  • Minimum expected quantity.
  • Source of minimum recommendation.
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
PS (17) — Product selection opportunity. TH (12) — Therapeutic interchange.*

*Action requires prescriber authorization.		 1E (14) — Filled with different drug. Level — Fee
11 — $14.68
12 — $22.16
13 — $22.16
14 — $40.11
15 — $40.11		 Not to be used with drugs on the Maximum Allowed Cost list.

Not to be used for generic substitution.

May only be used when therapeutic interchange results in drug cost savings.

Level 14 = maximum PC dispensing fee.

Note: The prescriber must be contacted for interchanges.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify initial drug prescribed.
  • Summary of any communication with prescriber.
  • Changes made to drug(s), dose, frequency, directions, or quantity prescribed.
  • Indicate cost savings.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
RE (84) — In-home medication management. AS (20) — Evaluation of information known by the pharmacist or supplied by the member for the purpose of developing a problem-based therapeutic plan. 2A (30) — Order not filled.

3M (80) — Compliance aid developed.		 Level — Fee
14 — $40.11		 A maximum of one RE (84) PC dispensing fee per member, per day.

Not available for nursing home residents or members receiving home health nurse services on the same days services are billed by home health.

Service must be delivered by a pharmacist or other licensed health care professional.

Physician order is required.

Note: Reason code 84 must always be billed at Level 14.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identification of drug(s) (when dispensed at same time as intervention).
  • Describe the medication management.
  • Describe the actions taken to solve the medication management problem and how it meets the member's needs.
  • Documentation of contact with physician ordering intervention.
  • Summarize the training provided to member in use of the medication. Include basis for recommendation.
  • R. Ph. identification.
  • Copy of physician order.
  • Describe the compliance aid developed and how it meets the member's needs.
CC (21) — Coordination of care.

M0 (22) — Prescriber contacted.

MR (23) — Comprehensive review and evaluation of the member's complete known medication regimen.

PE (25) — Verbal or written communication to the member by a pharmacist to enhance the member's knowledge about the condition under treatment or to develop skills and competencies related to its management.		 2A (30) — Order not filled.

3K (85) — Member demonstrates understanding of proper medication use.		 Level — Fee
14 — $40.11		 A maximum of one RE (84) PC dispensing fee per member, per day.

Not available for nursing home residents or members receiving home health nurse services on the same days services are billed by home health.

Service must be delivered by a pharmacist or other licensed health care professional.

Physician order is required.

Note: Reason code 84 must always be billed at Level 14.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identification of drug(s) (when dispensed at same time as intervention).
  • Describe the medication management.
  • Describe the actions taken to solve the medication management problem and how it meets the member's needs.
  • Documentation of contact with physician ordering intervention.
  • Summarize the training provided to member in use of the medication. Include basis for recommendation.
  • R. Ph. identification.
  • Copy of physician order.
  • Describe the compliance aid developed and how it meets the member's needs.
SC (83) — The member needs medication management assistance due to documented compliance problems. AS (20) — Evaluation of information known by the pharmacist or supplied by the member for the purpose of developing a problem-based therapeutic plan. 3M (80) — The pharmacist designed, implemented, and provided member- specific training for a specific compliance aid program such as a "pill minder" or "punch card" system for in- home use. Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $40.11
15 — $40.11		 Maximum of two SC (83) PC dispensing fees per member, per year.

Not billable for nursing home residents.

Level 14 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Describe the compliance problem, including the actual or potential negative member outcome of continued non-compliance.
  • Describe the compliance aid and how it meets the member's needs.
  • Summarize training provided to member in use of the compliance aid.
  • Pharmacist's name.
SE (95) — The pharmacist determines it necessary to provide information regarding possible side effects of a drug prescribed for this member. Side effect precautions include: Iatrogenic drug condition, drug- disease precaution, lactation precaution, drug-age precaution, drug-sex precaution, drug-food, drug-lab, drug-tobacco, drug-alcohol precautions. M0 (22) — Prescriber contacted. 1C (12) — Order filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Order filled with a different drug.

1K (18) — Order filled with a different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of four SE (95) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when no replacement drug is prescribed.

Not billable for nursing home residents.

Level 12 = maximum PC dispensing fee for member education when the prescriber is not contacted.

Level 13 = maximum PC dispensing fee if the prescriber is contacted.

Note: Routine intervention is part of normal prospective Drug Utilization Review (DUR) and consultation and is reimbursed under the traditional or unit dose dispensing fee when the prescription is dispensed.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Summary of intervention.
  • Summary of side effect precaution for this drug and member.
  • Identify drug not filled.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
PE (25) — Patient Education. 3K (85) — Instructions understood. Level — Fee
11 — $9.45
12 — $14.68
13 — $14.68
14 — $14.68
15 — $14.68		 A maximum of four SE (95) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when no replacement drug is prescribed.

Not billable for nursing home residents.

Level 12 = maximum PC dispensing fee for member education when the prescriber is not contacted.

Level 12 = maximum PC dispensing fee if the prescriber is contacted.

Note: Routine intervention is part of normal prospective Drug Utilization Review (DUR) and consultation and is reimbursed under the traditional or unit dose dispensing fee when the prescription is dispensed.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Summary of intervention.
  • Summary of side effect precaution for this drug and member.
  • Identify drug not filled.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
SF (34) — Prescribed dosage form may be incorrect, inappropriate, or less than optimal for treating this member. M0 (22) — Prescriber contacted. 1E (14) — Order filled with different drug.

1K (18) — Order filled with different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two SF (34) PC dispensing fees per member, per year.

An SF (34) PC dispensing fee may not be claimed if titration is determined to be the basis for the less than optimal therapy.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Nature of problem with dosage form.
  • Identify drug.
  • Summary of and basis for recommendation(s).
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
SR (36) — Prescribed drug regimen may be incorrect or less than optimal for treating this member. M0 (22) — Prescriber contacted. IC (12) — Order filled with a different dose.

1D (13) — Order filled with different directions.

1F (15) — Order filled with different quantity.		 Level — Fee
11 — $9.45
12 — $9.45
13 — $9.45
14 — $9.45
15 — $9.45		 A maximum of four SR (36) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 11 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify questioned drug(s).
  • Nature of problem with regimen.
  • Summary of and basis for recommendation(s).
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
1K (18) — Order filled with a different dosage form.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of four SR (36) PC dispensing fees per member, per year.

Result code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify questioned drug(s).
  • Nature of problem with regimen.
  • Summary of and basis for recommendation(s).
  • Outcome including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
TD (59) — Member's drug regimen includes simultaneous use of one or more drugs with the same therapeutic effect or which contain identical generic chemical entities which may be inappropriate. M0 (22) — Prescriber contacted. 1E (14) — Order filled with different drug.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $22.16
14 — $22.16
15 — $22.16		 A maximum of two TD (59) PC dispensing fees per member, per year.

Result Code 2A (30) may only be indicated when a replacement drug is not prescribed.

Level 13 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Identify drugs.
  • Nature of multiple drug problem.
  • Summary of and basis for recommendation(s).
  • Outcome, including summary of any communication with prescriber and member.
  • Indicate if intervention was for safety, efficacy, compliance, or cost savings-only purposes.
  • Diagnosis, diagnosis code, or intended use of medication involved in the submitted intervention.
  • Pharmacist's name.
TN (85) — Based on medication profile review or member consultation, the pharmacist determined one or more laboratory tests should likely be performed. RT (30) — The pharmacist recommends to the physician the performance of a clinical laboratory test for the member. 1C (12) — Filled with different dose.

1D (13) — Order filled with different directions.

1E (14) — Filled, different drug.

1K (18) — Filled, dose form change.

2A (30) — Order not filled.		 Level — Fee
11 — $9.45
12 — $14.68
13 — $14.68
14 — $14.68
15 — $14.68		 A maximum of one TN (85) PC dispensing fee per member, per year.

Not billable for nursing home residents.

Level 12 = maximum PC dispensing fee.
  • Date of intervention.
  • Professional time spent on intervention (minutes). Exclude documentation time.
  • Time spent on documentation (minutes).
  • Lab test recommended.
  • Summary of communication with the prescriber.
  • Pharmacist's name.