DAW Codes: What Pharmacies Need to Know

What can pharmacies do about it

There are two things a pharmacy can do to avoid common DAW code pitfalls.

1. Ensure your team knows the correct DAW code to apply based on the prescription scenario. Download the Net-Rx DAW Code Reference Chart
2. Pre-edit and Post-edit pharmacy technology solutions are available to work as safeguards to help catch potential billing errors or missed opportunities, both before and after claim adjudication

A pre edit solution, like Script-IQ ^® can alert the pharmacy of current DAW usage, before claims are sent to the payer. This can help improve workflow, lead to fewer transactions (which may reduce transaction fees), provide risk avoidance, improve cash flow and optimize reimbursement. Take a look at the below examples:

• Suppose the claim is submitted with a brand that has an available generic, but the DAW code is 0 or blank. In that case, a pre-edit can notify the pharmacy so they can either switch to a generic equivalent or use a proper DAW code based on the prescriber's order.
• Pharmacist usage of  DAW 3 rarely results in reimbursement at the contracted rate and should always be verified and well-documented. A pre-edit will help identify these so the pharmacy can review and adjust the claim before adjudicating it to the payer.
• DAW 4 often results in a generic rate payment. An alert to the usage of this code will allow the pharmacy to review their inventory and determine if they have the option of switching to the generic or if they can order the brand and utilize a more appropriate DAW code to ensure maximum reimbursement.
• A pharmacy's usage of DAW 5 may price a brand drug as a generic and result in under-reimbursement. Messaging from a pre-edit will warn the pharmacy to determine if changes are necessary to ensure optimized reimbursement and avoid audit triggers.

A post edit solution, like EditRx , will identify whether DAW code usage has led to under-reimbursement by third-party payers. It will also show generic rate payments on brand name drugs and identify substitution opportunities and overall DAW utilization by the pharmacy to improve future outcomes.

The chart below depicts just a small sample of claims in which missing or inappropriate DAW codes were submitted on brand-name drugs that have available generic alternatives. As a result, the prescriptions were paid at a generic MAC rate, which also lead to negative profits for the pharmacy.

Here are just some of the ways a post-edit solution can highlight opportunities:

• Post-edits can  identify DAW codes used on prescriptions that do not require or should not include a DAW , such as generics, single source brands, or OTC (Over the Counter) medications. A post-edit report can identify these claims, enabling the pharmacy to make adjustments as necessary and inform staff of proper DAW usage on future claims.
• Outdated usage of  DAW 7 , DAW 8 , or DAW 9 can result in low reimbursement or losses. Plans update their formularies, new generics enter the market, and patients switch from Medicaid to private insurance, rendering previously submitted DAW codes invalid. Post-edits can identify reimbursement changes on these claims. The pharmacy can switch to the generic or the new preferred medication and remove the invalid DAW code to avoid generic rate payments on brand-name drugs.
• Post-edit solutions can allow the pharmacy to see  generic substitution opportunities that may have been missed during the billing process. The pharmacy may want to review the payer messaging on claims submitted with DAW 2 to determine if/when the prior authorization is set to expire. With this information, the pharmacy can proactively reach out to the doctor to extend the prior authorization or discuss with their patient the benefits of switching to generic (i.e., lower copay).
• Claims submitted with DAW codes often require supporting documentation from the payer explaining why the specific DAW code was used. To prepare for retrospective payer reviews, the pharmacy can identify all DAW claims with post-edit reporting. The reports help assess internal records to ensure the proper documentation is in order should a payer audit arise.

Understanding the different DAW codes and how to apply them appropriately is an important first step in pharmacy billing. When there is an error or discrepancy with the DAW code, it can eat into your profits, lead to potential audit triggers, affect reimbursement, and disrupt workflow. Applying pharmacy technology like pre-edit and post-edit solutions can help pharmacies identify code usage before and after adjudication of claims. These solutions go hand in hand, allowing the pharmacy to confirm whether the codes submitted are accurate, if the claim requires modification or if the drug dispensed needs to be switched to a therapeutic or generic equivalent alternative. Together, these solutions can help ensure your pharmacy uses DAW codes accurately for optimized reimbursement, reduced rejections, and reduced potential for audit triggers.

If you would like to learn more about the pre and post edit solutions offered by Net-Rx™, please contact us.

Source:
¹ Net-Rx Brand Claims Study, December 2020, M. Peterkin

Author

Wanda Lund    Product Lead    Joined Net-Rx in 2009