Coding alignment to support whole-person health
Challenges with coding data misalignment
Payers are challenged with different coding structures as they create benefit designs in addition to working with different coding processes internally. On the medical benefit side, provider coding can come from different sources—such as HCPCS, ICD-10, CTP, and more—all of which need to be funneled through medical conditions, medical indicator codes, Generic Product Indicators (GPIs), and then aligned into NDC drug codes for the pharmacy benefit teams.
As drugs become more complex, both medical and drug policy teams need clear communication and code mapping to align benefits and coverage. Without this, challenges can include:
- A lack of visibility into the entire drug spend, because not all drugs are coming through pharmacy benefits
- Data interoperability challenges limiting awareness into the medical benefits side
- Improper and/or complex code mapping between drug and medical benefit teams to understand drug indicators
- Incorrectly entered codes impacting drug coverage or member safety
- Members becoming frustrated with coverage errors or miscommunication of benefits
Specialty drugs complicate code mapping
As specialty drugs increase in use and for different indicators, drug benefit teams need both coding alignment and the latest evidence to understand how and why drugs are being prescribed. In the case of semaglutide products, the majority are currently used for diabetes management, but Weygovy also received indication approval from the FDA for general weight loss as a diabetic preventative measure. The ICD-10 codes need to seamlessly map to the proper NDC codes for the respective semaglutide product to save drug policy teams the time and effort of understanding which drug product to cover.
In the face of evolving medical evidence, it’s crucial for policy teams to have the correct indication codes and align with the respective approved drug coverage. Having a robust data and analytics strategy is the foundation for improving policy coverage, benefit design, and member experiences.
Benefits of bringing medical and pharmacy data together
When drug and medical benefit teams are aligned with data and proper code mapping, health plans can have more insight into their members’ health and work towards a whole-person approach to wellness. Not every provider will have access to a member’s complete prescription history and polypharmacy—health plan teams need internal alignment founded on evolving evidence to understand indications and ensure safe drug approvals.
Internal operational efficiencies
The foundation for a more robust data strategy is having a clear mapping alignment and data normalization between pharmacy NCD drug codes and provider-based HCPCS and ICD-10 codes. When pharmacy and medical benefit teams have better insight between medical indicators and drug prescriptions, it can improve internal efficiencies, actuarial forecasts, and targeted interventions as well as member safety.
It can also help reduce costly searches for the proper indications for drug prescriptions, reduce human errors, and mitigate member frustrations. The challenge will be getting this mapping right to ensure accuracy so members are receiving the right health information, the right coverage, and the right support. Efforts can start with targeted drugs and populations and expand as the mapping is refined and evidence-based medicine evolves.
