All You Want To Know About Pharmacy Billing

In healthcare services, pharmacy billing is a crucial aspect. Like other healthcare disciplines, pharmacy billing too has its challenges, which are integral to pharmaceutical companies. There are some drugs and injections that are excluded from the coverage provided by the insurance. It eventually adds to the complexity of the pharmacy medical billing and coding. It is therefore essential that to know about the pharmacy billing staff have a thorough knowledge and understanding of the efficacy that includes and excludes the drugs and other items during the billing process.

Overall, pharmacy billing plays an effective part in the patient’s care and the revenue cycle management of a facility.

Understanding Pharmacy Billing?

The management of is Pharmacy billing and coding handled best when a professional takes over the work. With the customized and thorough billing service, the pharmaceutical company and the medical services can focus on their core aspect while the professional take care of the billing.

Types of Pharmacy Billing

You should be aware of the different categorizations of pharmacy billing which are as follows:

  • Home care pharmaceutical billing

In today’s healthcare system, there are many home-bound patients. For this pool of patients, the data needs to be maintained and handled efficiently. Pharmacy billing and coding experts might have to visit the patient’s home to collect the bills, and there is no room for error when submitting a claim.

  • Managed care

Managed care is operated from care centres and big hospitals, and the bills are reimbursed via a bundled payment model. It hence requires precise paperwork and data handling for maintaining the non-clinical reports.

  • Radio

One of the most proficient adjunct services is the radio drug. Accurate pharmacy coding is required to fulfil a full-proof pharmacy billing and coding and to get the maximum deliverables with this service. 

Factors Impacting Reimbursement of Pharmacy Billing

A report published by Drug Trend predicted that the price increase from biotech and traditional branded drugs would continue to increase due to the lack of generic drugs. CMS has further reduced the Average Sales Price (ASP) from six to four percent for non-pass-thorough drugs. As a result, it has affected the reimbursements of the pharmacies. Certain other aspects can impact the reimbursement process of the pharmacy billing and coding if the revenue cycle management is not implemented correctly.

Some of the factors that impact pharmacy billing and coding reimbursements are:

Data Workflow

To ensure full reimbursement for a drug sold or administered, the pharmacy must take care of the entire workflow. It starts with the procurement, inventory, and billing, the process of purchasing the medication, storing, and method of administering or dispensing it to the reimbursement. The way the pharmacy codes and bills it is also an essential part of the procedure. If any information entered is incorrect, the revenue cycle will be disrupted. Also, the reimbursement of the drug fails to be realized.


This phase is vital in converting the purchased quantities and pricing information to the storage unit of measure. It also takes into account the costs of inventory. Any mistake at this phase can disrupt the revenue cycle management.

Charge Master

Often in pharmaceutical billing, a revenue leakage occurs at this phase when reimbursable medications are miscoded or missing in the chargemaster. The pharmaceutical quantities are required to convert from the amount purchased to the amount administered to the patients. The drug can be billed only when a proper charge master is in place.


Every drug needs to be codded appropriately with the HCPCS code. Any incorrect coding in the chargemaster means the liability is shifted to the payer or the patient. It then leads to the hospital or the health service provider being unable to get the reimbursement.

Linkage between Purchase and Billing

Typically a hospital maintains a separate process for ordering drugs, administering them, and processing the reimbursement. However, every hospital should have an automated tool to keep a linkage between all three to ensure no error and a proper refund can occur.

Rules, Regulations & Compliances

The company’s admin should be able to keep track of all the CMS regulations and ongoing changes related to the drugs and pharmaceutical billing. It will ensure lowering the risk of reimbursement rejection and maintaining the revenue cycle management running smoothly.

Wants to Get Reimbursed for Your Drugs Every time?

It’s time to let someone else, an expert do the heavy loading with the complex nature to know about pharmacy billing and coding while you can focus on your core objective. Working with a third party to whom you can outsource pharmacy billing and coding and revenue cycle management is the best way to ensure you get reimbursed for your services.

We at 24/7 Medical Billing Services work very closely with medical health facilities of all sizes and helps to know about pharmacy billing and coding to ensure the revenue cycle management is at the top. A team of experts is always there to help you while you take care of serving the patients better.

Read more: Are Your Pharmacy Billing Collections Below The Expectations?

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