Intervention & Exception Codes

FHIR: Claim.Item.Modifier
CPHA - Intervention & Exception Code

http://pharmacyeclaims.ca/FHIR/CodeSystem/intervention-codes

http://pharmacyeclaims.ca/FHIR/CodeSystem/DUR-codes

Two character codes are used. This permits 2 codes to be submitted in a transaction in a CPHA protocol. For the FHIR specification, up to 10 codes are permitted in the request message.

These codes will be submitted in the request using the Claim.item.modifier data element. Often these codes are provided to the Pharmacy during support calls with the Adjudicator, where exceptional circumstances exist. The code provides further context to the claim and often results in an override on the ajudication system.

Backwards Compatibility All codes must remain in order to support adjudicators who will translate the FHIR claim into a CPHA claim. Some codes will be moved to more appropriate fields in the FHIR standard.

http://pharmacyeclaims.ca/FHIR/ValueSet/intervention-codes

Code	Notes
A
AA = Fill despite prior substance use
AB = Benefit outweighs risk
AE = ADE report erroneous
AI = ADE alert inappropriate
AK = ADE acknowledged and prescription changed
AR = ADE refuted.
AT = ADE resolved/treated.
B
BP = bypass processor edit
C Codes Refusal to Fill	**"C" codes	consider moving to Not Performed Reason (new extension)
CA = prior adverse reaction	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CB = previous treatment failure	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CC = allergy to product is on record
CD = therapeutic duplication	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CE = product choice is not reasonable
CF= falsified or altered prescription	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CG = Rx not filled, days supply is unsuitable
CH = dangerously high dose	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CI = significant drug interaction	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CJ = product is not effective
CK = quantity prescribed is not rational
CL= sub-therapeutic dose	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CM = suspected multi-pharmacy/multi doctor	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CO = potential overuse/abuse	Table 2 - the provider (pharmacy) uses to communicate various cautionary concerns to the processor.
CP = prescription is too old
CS = was preauthorised by telephone
D
DA = secondary claim - orig to prov plan	deprecate
DB = secondary claim - orig to other carriers	deprecate
DC = out of pocket expense paid by insured
DD = out of pocket exp pd by insured spouse
DE = adjudicate to $0.00 as requested
DF = medication billed via family member ID
DG = same product – billed for different Rx
DH = Rx synchronized pursuant to rule 19
DI = advanced, pharmacy closed on renewal date
DJ = advanced, unable to deliver on renewal date
DK = exception, drug used in 2 separate locals
DL = exception, need drug for medical appointment
DM = exception, renewal preauthorised by RAMQ
DN = exception, long term Rx preauthorised by RAMQ
DO = changed dosage – dosage too high
DP = drug cost verified – invoice to follow
DQ = professional fee is appropriate
DV = applied to prov. plan and approved
DW = applied to prov. plan and rejected
DX = applied to prov. plan, decision pending
DY = not eligible for prov. plan coverage
E
EA = pharmacist authorized off-hours claim
EB = supplementary renewal – prescriber absent
ED = exception drug status prescriber choice
EO = early renewal, exception status indicated
EP=exception drug status pharmacist choice
EQ= valid reason to exceed days supply limit
ER = override days supply limit for period
ES=override concurrent therapy requirement
ET= override questionable concurrent therapy
EU = provincial coverage waived by patient
EV = co-pay not collected - item is exempt
F
FA = expect treatment period to change
FB = second service required same day
FC = RAMQ re-authorized anticipated renewal
H
HT= home parenteral therapy
I
IA = for asthma & chronic pulmonary diseases	Diagnosis?
IB = chronic pulmonary disease is not controlled
IX = covered indication is absent or inconsistent
L
LU = start new Limited Use authorization
M
MA = Long Term Care filled early for stat holiday
ME = valid claim - primary validation level
MF = valid claim - historical validation level
MG = override - various reasons
MH = override - prescriber ID
MI = no interchangeable available at less than or equal to BAP plus 10 PCT
MJ= government pharmacy authorized claim
MK = good faith emergency coverage established
ML= good faith standard coverage established
MM = replacement claim, drug cost only
MN = replacement claim due to dose change
MO = valid claim - value $500.00 to $999.99	DEPRECATE
MP = valid claim - value $1,000.00 to $9,999.99	DEPRECATE
MQ = valid claim - quantity over limit
MR = replacement, item lost or broken
MS = non-formulary benefit
MT = trial Rx program	DEPRECATE, Dispense.type will be used
MU = limited use product
MV = vacation supply
MW = valid reason to exceed good faith limit
MX = long term care PRN order
MY= long term care Rx split for compliance
MZ = required prior therapy documented
N
NA = valid claim - primary validation level
NB = valid claim - validation on file
NC = patient SDP eligibility confirmed
ND = trial prescription balance	DEPRECATE
NE = ineligible for trial Rx
NF = override - quantity appropriate
NG = drug interchanged-Y2K shortage	DEPRECATE?
NH = initial Rx program declined
NI = dosage change
NJ = formulation change
NK = directions for use modified
NL = renewal of prescription	can we instead use New/Refil Code, R=prescription refill/repeat
NM = therapeutic substitution
NN = emergency supply of medication
NO = emergency contraceptive
NR = nonreturnable drug reimbursement
P
PA = valid health card version code
PB = name entered is consistent with card
PC = patient does not meet exception criteria
PS = professional care service	Professional Services	imply from trxn id; used by Ontario and maybe others
R
RA = Due to ADE alert	Alert
RC = prescription cancelled by physician	Reversal reason?
RD = Defer clinical decision
RE = claim reversed - data entry error	Reversal reason
RO = Override alert
RR = prescription refused by patient	Reversal reason
U = claim reversed - not called for	Reversal???
S
SL= second line drug prescribed by specialty
SP = 1st forgiveness allowed for Specialty Program (SP)
SS = approved by prov, bypass others, allow 1st forgiveness for SP
ST = rejected by prov, bypass others, allow 1st forgiveness for SP
SU =pending by prov, bypass others, allow 1st forgiveness for SP
SV = approved by prov plan, bypass other programs
SW = rejected by prov plan, bypass other programs
SX = pending prov plan, bypass other programs
T
TB = ECO therapy lost, broken or spoiled by patient
TC = ECO therapy begun Friday AM at hospital
TP = ECO therapy with change of dosage
TR = ECO therapy lost, broken or spoiled by carrier
TS = Maintain product stability for short term
U	Table 4 - Mitigation Codes Used to indicate what action was taken as the result of an intervention.**
UA = consulted prescriber and filled Rx as written	Table 4
UB= consulted prescriber and changed dose	Table 4
UC= consulted prescriber and changed instructions for use	Table 4
UD= consulted prescriber and changed drug	Table 4
UE = consulted prescriber and changed quantity	Table 4
UF = patient gave adequate explanation. Rx filled as written	Table 4
UG = cautioned patient. Rx filled as written	Table 4
UH = counselled patient. Rx not filled	Table 4
UI = consulted other source. Rx filled as written	Table 4
UK = consulted other sources. Rx not filled	Table 4
UL= Rx not filled – pharmacist decision	Table 4
UM = consulted prescriber, Rx not filled	Table 4
UN=assessed patient, therapy is appropriate	Table 4
UO = valid reason to use alternative therapy
UP = first line therapy ineffective
UQ =first line therapy not tolerated by patient
UT= treatment of acute condition
UU = therapeutic emergency
UY = extemp mixture dispensing fee limit override
UX =emergency dispensing fee limit override
V	TRIAL RX
VC = trial Rx program refused by patient
VD = patient unavailable to receive trial Rx balance
VE = treatment of acute condition
VF = trial Rx balance urgently needed
VG = professional service fee not to be paid
VH = trial Rx refused by physician
VI = trial Rx refused by pharmacist
VJ = trial Rx refused by patient=s agent
VK = trial balance not filled
VL = consulted MD, patient return requested
VM = trial not tolerated, referred patient to MD
VN = trial not tolerated, patient advised MD
VO = trial ineffective, referred patient to MD
VP = trial ineffective, patient advised MD
VQ = trial OK, no side effects/concerns
VR = trial OK, concerns OK after counselling
VS = other outcome or intervention
VT = trial not required - adequate Dr’s sample
VU = do not contact patient re evaluation
VV = patient agrees to evaluation contact
VW = therapy changed or discontinued
VX = clinical condition / symptoms improving
VY = patient reports side effects or ADR
VZ = more time required to assess therapy
X
XA = reversal amount error	????? error???
XB = previously rejected transaction not found
XC = provider transaction date valid for OLT