Billing for Nebulizer Vials

[Pianopooh]

A patient came in with a script for nebulizer vials with a quantity of "360." Patient proceeds to tell me the prescriber (ANP) meant to give a 3 month supply. However, the box unit is 3ml x 5 vials x 6 packs = 90 ml. The direction was to use 1 vial every 6 hours. This meant the patient uses 4 vials a day.

4 vials x 3 ml/day x 30 days = 360 ml. I gave the patient 4 boxes (90 ml/box).

Patient claims they should receive 4 vials x 30 days = 120 vials, with a 3 month supply of 360 vials.

I explained to the patient when we bill for liquids, we bill for volume. Patient gets upset, insults my understanding of English, and proceeds to tell me I'm an intern with no knowledge of what to do. So I explain to the patient for example, we bill Fluticasone as 17g, not "1" box. It's the volume, not the box. We bill Amoxicillin suspensions as 100ml, not "1" bottle. Patient proceeds to tell me I raised by voice, in which my pharmacy team members tell the patient to calm down because they were the one with the voice raised.

In this scenario I suggested I would call the ANP but patient told me not to since the ANP is not in the hospital (??) and that they would straighten it out themselves. I told the patient to see the pharmacist or another tech to further receive clarification (this was drop-off, 10 minutes later, with a long line).

Anyway, from this story here are the following thoughts because I work in community/retail setting and we're told to be kind to all patients:

1. My billing explanation was clear, was it not?

2. Patient claims they work in healthcare and a script from their own office of "360" would mean 3 month supply. I wanted to respond to the patient that they haven't worked in a pharmacy before, so he/she would not understand how to exactly bill for these items. But I didn't do so, point #3 --

3. Tech told me I should have just told this person to back off, they insulted my intelligence, and I shouldn't have been so nice. In reality, this stuff doesn't phase me anymore and if the patient/customer wants to scream at me, it doesn't hurt my feelings. However, I am just not aware of how this one particular patient will affect how the other patients will see the pharmacy (despite my thorough explanation, because the other patients will immediately only see that this person didn't get what they wanted).

Lastly, for those in retail/community setting, did you get a lot of requests from patients who wanted to commit insurance fraud? I received a lot of requests for patients who wanted to get another refill before their insurance expires, even though they previously had a 3 month supply of a medication and used up one month of it (they still had 60 days worth of meds) but wanted another month of it! Etc, and other odd requests.

This transition of last week of the year into the first new week of the year brings out the worst in patients it seems.

PS - I work at CVS pharmacy, and my name tag is not an Americanized name (hence, patient thought I didn't know how to speak English, until I started speaking to him/her in full sentences w/o an accent). I want to keep my un-Americanized name tag from now on!

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[Old Timer]

A patient came in with a script for nebulizer vials with a quantity of "360." Patient proceeds to tell me the prescriber (ANP) meant to give a 3 month supply. However, the box unit is 3ml x 5 vials x 6 packs = 90 ml. The direction was to use 1 vial every 6 hours. This meant the patient uses 4 vials a day.

4 vials x 3 ml/day x 30 days = 360 ml. I gave the patient 4 boxes (90 ml/box).

Patient claims they should receive 4 vials x 30 days = 120 vials, with a 3 month supply of 360 vials.

I explained to the patient when we bill for liquids, we bill for volume. Patient gets upset, insults my understanding of English, and proceeds to tell me I'm an intern with no knowledge of what to do. So I explain to the patient for example, we bill Fluticasone as 17g, not "1" box. It's the volume, not the box. We bill Amoxicillin suspensions as 100ml, not "1" bottle. Patient proceeds to tell me I raised by voice, in which my pharmacy team members tell the patient to calm down because they were the one with the voice raised.

In this scenario I suggested I would call the ANP but patient told me not to since the ANP is not in the hospital (??) and that they would straighten it out themselves. I told the patient to see the pharmacist or another tech to further receive clarification (this was drop-off, 10 minutes later, with a long line).

Anyway, from this story here are the following thoughts because I work in community/retail setting and we're told to be kind to all patients:

1. My billing explanation was clear, was it not?

2. Patient claims they work in healthcare and a script from their own office of "360" would mean 3 month supply. I wanted to respond to the patient that they haven't worked in a pharmacy before, so he/she would not understand how to exactly bill for these items. But I didn't do so, point #3 --

3. Tech told me I should have just told this person to back off, they insulted my intelligence, and I shouldn't have been so nice. In reality, this stuff doesn't phase me anymore and if the patient/customer wants to scream at me, it doesn't hurt my feelings. However, I am just not aware of how this one particular patient will affect how the other patients will see the pharmacy (despite my thorough explanation, because the other patients will immediately only see that this person didn't get what they wanted).

Lastly, for those in retail/community setting, did you get a lot of requests from patients who wanted to commit insurance fraud? I received a lot of requests for patients who wanted to get another refill before their insurance expires, even though they previously had a 3 month supply of a medication and used up one month of it (they still had 60 days worth of meds) but wanted another month of it! Etc, and other odd requests.

This transition of last week of the year into the first new week of the year brings out the worst in patients it seems.

PS - I work at CVS pharmacy, and my name tag is not an Americanized name (hence, patient thought I didn't know how to speak English, until I started speaking to him/her in full sentences w/o an accent). I want to keep my un-Americanized name tag from now on!

First, when a patient becomes abusive, you call the pharmacist. It's their job to deal with the nitwits.

Next, explain the prescriber was unclear. He had the option of writing disp:

• 90 day supply
• 360 ml
• 360 vials

Since the prescriber was unclear as to how much medication he/she wanted to dispense, you would dispense the 360ml and then call the prescriber the next time they were in the office and adjust the quantity accordingly after consultation with the prescriber. Further inform the patient you would call him/her as soon as the issue is resolved.

Don't hide your name, if people can't deal with the fact you don't have an Americanized name, they are *******s. Every American is ultimately from somewhere else, unless they have red skin.

 

[MountainPharmD]

This comes up quite often. If you think it through it is not that hard. The inner workings or your pharmay computer system has no bearing on this. Do you think the Doctor, NP or PA has any clue how your computer system bills nebulizer solution?

A patient came in with a script for nebulizer vials with a quantity of "360."
Patient claims they should receive 4 vials x 30 days = 120 vials, with a 3 month supply of 360 vials.

There is your answer. The prescription had a quantity of 360. So you dispense 360 vials with a 90 day supply. Think about this from the prescribers point of view. When they write the prescription they have no clue what the volume of each vial is. Even if they did why would they write a quantity based on the contents of each prefilled vial? That would be like writing for Amlodipine 10 mg and writing the dispensed quantity as total milligrams dispensed verse the number of tablets. Have you ever seen a script for Amlodipine 10mg quantity 900 mgs?

1. My billing explanation was clear, was it not?

2. Patient claims they work in healthcare and a script from their own office of "360" would mean 3 month supply. I wanted to respond to the patient that they haven't worked in a pharmacy before, so he/she would not understand how to exactly bill for these items. But I didn't do so, point #3 --

Yes, your billing explanation was clear. However, it has no bearing on this at all. The patient does need nor do they want a detailed explanation of how you computer system works. I guarentee you the Doctor, NP or PA doesn't either. The bottomline is do not make things harder than they need to be. As an aside where was the pharmacist while this was going on or the lead tech? Someone should have stepped in and helped you on this.

 

[Pianopooh]

First, when a patient becomes abusive, you call the pharmacist. It's their job to deal with the nitwits.

Next, explain the prescriber was unclear. He had the option of writing disp:

• 90 day supply
• 360 ml
• 360 vials

Since the prescriber was unclear as to how much medication he/she wanted to dispense, you would dispense the 360ml and then call the prescriber the next time they were in the office and adjust the quantity accordingly after consultation with the prescriber. Further inform the patient you would call him/her as soon as the issue is resolved.

Don't hide your name, if people can't deal with the fact you don't have an Americanized name, they are *******s. Every American is ultimately from somewhere else, unless they have red skin.

Thanks for your feedback. The pharmacist was busy with another patient who was giving grief at the register about their co-payment. I told the patient the pharmacist is busy and if they would like to wait, they can step to consultation and speak with the pharmacist. The patient elected not to do so.

Even though the patient told me not to bother calling the prescriber, I am going to call the prescriber on Monday just to clarify since I would like to know what the prescriber intended to write on the prescription. I don't know if I should contact the patient when I found out what the prescribers says. The scenario would be:

1) Prescriber says "360" as in 1 month, then i won't call the patient.
2) Prescriber says "90 day supply" and I adjust the prescription, but since the patient told me not to bother contacting the prescriber to begin with, then it would seem odd to contact the patient.

 

[Old Timer]

Thanks for your feedback. The pharmacist was busy with another patient who was giving grief at the register about their co-payment. I told the patient the pharmacist is busy and if they would like to wait, they can step to consultation and speak with the pharmacist. The patient elected not to do so.

Even though the patient told me not to bother calling the prescriber, I am going to call the prescriber on Monday just to clarify since I would like to know what the prescriber intended to write on the prescription. I don't know if I should contact the patient when I found out what the prescribers says. The scenario would be:

1) Prescriber says "360" as in 1 month, then i won't call the patient.
2) Prescriber says "90 day supply" and I adjust the prescription, but since the patient told me not to bother contacting the prescriber to begin with, then it would seem odd to contact the patient.

Please tell the prescriber nicely you don't bring your crystal ball to work. They need to clearly write how much medication they want. 360cc, 360 vials, etc... The other thing that mitigates in your favor is who uses a nebulized albuterol 4 x per day every day? This is very unusual.......

 

[Pianopooh]

This comes up quite often. If you think it through it is not that hard. The inner workings or your pharmay computer system has no bearing on this. Do you think the Doctor, NP or PA has any clue how your computer system bills nebulizer solution?

I did not blame my pharmacy computer system on how the billing is done, nor did I put blame on how the prescriber should know how the pharmacy's computer system work. I am clearly stating based on how the prescription is written, I have to input the quantity as legally acceptable by the insurance. That is how the billing is done.

There is your answer. The prescription had a quantity of 360. So you dispense 360 vials with a 90 day supply. Think about this from the prescribers point of view. When they write the prescription they have no clue what the volume of each vial is. Even if they did why would they write a quantity based on the contents of each prefilled vial? That would be like writing for Amlodipine 10 mg and writing the dispensed quantity as total milligrams dispensed verse the number of tablets. Have you ever seen a script for Amlodipine 10mg quantity 900 mgs?

As stated in the first post, the billing was done for an item that is in liquid volume. Your example of Amlodipine is for a tablet. Tablets or capsules would not be presented on a prescription as their complete dosage quantity. The example you gave is faulty, as my rebuttal would be, have you seen a script written for Plavix 75mg as 2250mg for 30 day supply? No, I have not. Nor have I have seen it from my experience in the pharmacy or from school assessments. But I have seen 200ml written for Amoxicillin Suspension (available in 50ml, 100ml).

In fact, prescribers have a handbook where it informs them of what the medication package supply units come in. From my experience of interning at several MD offices, prescribers have several references including MPR (Monthly Prescribing Reference) which clearly states what one package is.

For example, let's use Accuneb: "How supplied: Vials (3ml) - 25"

Or, Brovana: "How supplied: Vials (2ml) - 30"

Yes, your billing explanation was clear. However, it has no bearing on this at all. The patient does need nor do they want a detailed explanation of how you computer system works. I guarentee you the Doctor, NP or PA doesn't either. The bottomline is do not make things harder than they need to be. As an aside where was the pharmacist while this was going on or the lead tech? Someone should have stepped in and helped you on this.

I did not go through in details of how my computer system works. I only explained to the patient why they were not receiving the quantity of 3 months as they believed they would have gotten. I explained how the calculation was done for 1 month supply based on what's written on the script. Their insurance may have paid for 3 months supply, but I am billing based on what the prescription is written for.

On contrary of what you stated in the patient not caring about how the insurance billing is done (and by billing, I think you are confusing how I type the script into the computer vs what the insurance is paying for), if the patient understand how billing is done (not just at my pharmacy, but at other pharmacies), they can ask for the proper way of writing a prescription in the future for their 3 month supply; so it is in the patient's benefit to understand how they can get their 3 month supply.

The pharmacist and lead technician were both busy. I asked the patient to wait a few minutes if they wanted an explanation that was more in depth. He/she decided to pass on it.

 

[johnep34]

In the UK 360 would normally mean 360 nebules. We only have volume involved with controlled drugs.
Very common for hospital Drs to state termas 7/7 1/52, 1/12 etc. If unclear we would give month's supply and tell pt to get repeat (refill) from GP.
johnep

 

[MountainPharmD]

I did not blame my pharmacy computer system on how the billing is done, nor did I put blame on how the prescriber should know how the pharmacy's computer system work. I am clearly stating based on how the prescription is written, I have to input the quantity as legally acceptable by the insurance. That is how the billing is done.



As stated in the first post, the billing was done for an item that is in liquid volume. Your example of Amlodipine is for a tablet. Tablets or capsules would not be presented on a prescription as their complete dosage quantity. The example you gave is faulty, as my rebuttal would be, have you seen a script written for Plavix 75mg as 2250mg for 30 day supply? No, I have not. Nor have I have seen it from my experience in the pharmacy or from school assessments. But I have seen 200ml written for Amoxicillin Suspension (available in 50ml, 100ml).

In fact, prescribers have a handbook where it informs them of what the medication package supply units come in. From my experience of interning at several MD offices, prescribers have several references including MPR (Monthly Prescribing Reference) which clearly states what one package is.

For example, let's use Accuneb: "How supplied: Vials (3ml) - 25"

Or, Brovana: "How supplied: Vials (2ml) - 30"



I did not go through in details of how my computer system works. I only explained to the patient why they were not receiving the quantity of 3 months as they believed they would have gotten. I explained how the calculation was done for 1 month supply based on what's written on the script. Their insurance may have paid for 3 months supply, but I am billing based on what the prescription is written for.

On contrary of what you stated in the patient not caring about how the insurance billing is done (and by billing, I think you are confusing how I type the script into the computer vs what the insurance is paying for), if the patient understand how billing is done (not just at my pharmacy, but at other pharmacies), they can ask for the proper way of writing a prescription in the future for their 3 month supply; so it is in the patient's benefit to understand how they can get their 3 month supply.

The pharmacist and lead technician were both busy. I asked the patient to wait a few minutes if they wanted an explanation that was more in depth. He/she decided to pass on it.

Wow....I have seen people who make things harder than they need to but you take it to a whole other level. This isn't hard. Over the years I have explained this to countless numbers of techs and interns.

Let me try and simplify this for you. Think of a nebulizer vial the exact same way you think of a tablet or capsule. A Doctor writes a prescription for Amlodipine 10mg 1 QD #30. Clear, unambiguous and no problem. Dispense 30tablets for a 30-day supply and move on. A Doctor writes a prescription for Albuterol 1 QID #360. Again clear, unambiguous and no problem right? Dispense 12 boxes of 30 with a 90 day supply and move on.

There is nothing hard or complicated about this. Again, how you input the prescription into the computer system has nothing to do with this. There is no need to call the prescriber. What are you going to say? Doc you wrote for 360 on the Albuterol. Is the 360 vials or 360 mls? That would be like calling the Doctor on a birth control prescription. Well Doc I was calling because you wrote Yasmin 1 QD #3. Did you want three tablets or three packs.

Do not make things harder than they need to be. Its complicated enough out there.

 

[ForgetMeNot]

That would be like calling the Doctor on a birth control prescription. Well Doc I was calling because you wrote Yasmin 1 QD #3. Did you want three tablets or three packs.

Do not make things harder than they need to be. Its complicated enough out there.

 

[Pianopooh]

Wow....I have seen people who make things harder than they need to but you take it to a whole other level. This isn't hard. Over the years I have explained this to countless numbers of techs and interns.

Let me try and simplify this for you. Think of a nebulizer vial the exact same way you think of a tablet or capsule. A Doctor writes a prescription for Amlodipine 10mg 1 QD #30. Clear, unambiguous and no problem. Dispense 30tablets for a 30-day supply and move on. A Doctor writes a prescription for Albuterol 1 QID #360. Again clear, unambiguous and no problem right? Dispense 12 boxes of 30 with a 90 day supply and move on.

There is nothing hard or complicated about this. Again, how you input the prescription into the computer system has nothing to do with this. There is no need to call the prescriber. What are you going to say? Doc you wrote for 360 on the Albuterol. Is the 360 vials or 360 mls? That would be like calling the Doctor on a birth control prescription. Well Doc I was calling because you wrote Yasmin 1 QD #3. Did you want three tablets or three packs.

Do not make things harder than they need to be. Its complicated enough out there.

But I digress, while your expertise tell you 360 means vials, I have been told to fill prescriptions of "360" as only a one month supply. We have filled countless prescriptions of nebulizers of 4 boxes/1 month supply, written in similar fashion. Like I have written in my OP, it's not about the input into the computer. It's about billing and filling the prescription as allowed by the legal boundaries, and whether or effectively communicated with the patient.

Once again, your prescription explanation of Yaz is of a tablet, and hence, faulty. Please refer to the explanation above (liquid vs tablet/capsule). Also, prescribers write "1 pack" or "3 month" as quantity for birth controls.

If you are billing for 360 vials for your pharmacy when the prescription is written just for "360" without documentation that the prescriber meant to write a 3 month supply, then I hope during audit checks your nebulizer prescriptions will be overlooked because you'll end up with a loss.

 

[MountainPharmD]

double post!

 

[MountainPharmD]

Okay, this is my last try to get through. You can make things harder than they need to be if you want.

But I digress, while your expertise tell you 360 means vials, I have been told to fill prescriptions of "360" as only a one month supply. We have filled countless prescriptions of nebulizers of 4 boxes/1 month supply, written in similar fashion. Like I have written in my OP, it's not about the input into the computer. It's about billing and filling the prescription as allowed by the legal boundaries, and whether or effectively communicated with the patient.

All I can say to this is a quantiy of 360 is a quantity of 360. It is not any harder than that. I do not need any expertise to read a number off a prescription.

Once again, your prescription explanation of Yaz is of a tablet, and hence, faulty. Please refer to the explanation above (liquid vs tablet/capsule). Also, prescribers write "1 pack" or "3 month" as quantity for birth controls.

Once again you are getting hung up on a liquid for some reason. Think of one nebulizer vial as being the same as one pill. We are not taking about a liquid because the nebulizer vial is a single use prepackaged unit. You are not making the vials with a stock bottle of Albuterol and pouring an amount into vials. You are confused because your pharmacy computer doesn't use one vial rather it uses the contents of the vial for the dispensed quantity.

If you are billing for 360 vials for your pharmacy when the prescription is written just for "360" without documentation that the prescriber meant to write a 3 month supply, then I hope during audit checks your nebulizer prescriptions will be overlooked because you'll end up with a loss.

Thank you for the advice pharmacy student. I have been a Pharmacy Manager since you were in middle school. I have been through many, many insurance audits. The last one was 2 months ago and I had zero dollars charged back to my pharmacy. So thanks for the advice but I know quite well what I am doing and how to run a pharmacy.

 

[Rebel78]

You've explained it plain as day 3 times MountainPharmD. If they don't get it by now, they'll figure it out one day.

 

[Pianopooh]

Thank you for the advice pharmacy student. I have been a Pharmacy Manager since you were in middle school. I have been through many, many insurance audits. The last one was 2 months ago and I had zero dollars charged back to my pharmacy. So thanks for the advice but I know quite well what I am doing and how to run a pharmacy.

You do not need to be sarcastic. I did not use that type of tone with you in my posts, and you do not need to respond in that type of way either. Pharmacies have ended up with losses because of the way medications are billed. I am stating a concern, but if you do not read it that way then that's unfortunate. I appreciate your feedback, but you and I have different points of view.

----------------------------------------------------
Lastly, I'm quite disappointed this is how professionals treat one another in this career. This is why so many students would rather just not post, because for some reason, every conversation ends up in the: "I know more than you do, because I have been around longer." That's great you've been around longer, it's just that I wasn't born earlier. But that should not discourage me from posting or sharing a point of view, and colleagues should share their experiences. Yes, I am a student. I am here to learn. If you don't want to teach me anything, then that's okay.

 

[Sparda29]

It seems like a really easy scenario here and you were wrong.

Look at the directions: they are using 4 vials every day. That means they need 120 vials in a month, hence 360 vials are in 3 months. The prescriber wrote for 360 without specifying if he meant ML or vials. Usually prescribers do not know how much volume is in each vial, thus when they write a prescription for something like this, they are talking about 360 UNIT DOSES.

360 unit doses = 90 days supply with the directions that were given. When you enter this into the system, simply multiply the amount of unit doses being dispensed by the volume of the liquid inside the unit dose, which is 3, thus you bill for 1080 ML.

This is not something that requires documentation, nor is this something that is gonna bite you in the ass when it comes to audits.

 

[CynicalIntern]

Since you keep getting hung up on volume and liquids, lets try this on for size.

One of the bowel prep kits, Trilyte or Nulytely or whatever else, gets processed through the insurance as a quantity of "1" because it's qualified as a kit. Others are processed as a quantity of "4000" measuring the internal volume of the kit. If the doctor writes for a quantity of 1 for the one that you bill "4000," are you really going to call the physician to clarify?

You're probably right, the doctor probably has a book somewhere in his office that gives the volume of a vial. They also probably don't care about it, nor do they have time. If I recall correctly, Ipratroprium has a vial size of 2.5 ml. Is anyone really going to multiply fractions to write a script?

Finally, nobody is treating anyone inappropriately in this thread. You're just indignant because MountainPharmD disagreed with you, and scoffed at your audacity to warn him about audits, when the most you've ever had to deal with them likely involves looking up hard copies and listening to the pharmacist complain about lost money. It's easy to see how you can make the mistake if you're not experienced, but if you truly want to learn like you said you do, then do it rather than trying to justify your mistakes.

Edit: Or, for the sake of argument, what if the nebulizer prescription had said "1". Do you dispense 1 vial? 1 nebulizer? Sure, some doctors will specify that they want 1 box, but there are plenty that won't.

 

[pinkpillowzz]

how about you just look at the script, see it says 360, see what the patient wants, and just fill it like that. 360 vials, 360 mls, whatever. then document it on the script. then patient doesn't get mad, you don't lose money in audits.

situations like this are nothing to get hung up over. it happens, don't let it affect you.

 

[Old Timer]

how about you just look at the script, see it says 360, see what the patient wants, and just fill it like that. 360 vials, 360 mls, whatever. then document it on the script. then patient doesn't get mad, you don't lose money in audits.

situations like this are nothing to get hung up over. it happens, don't let it affect you.

No, the order has to be appropriate. Why would anybody use nebulized albuterol qid every day for 90 days? What is the diagnosis? Asthma? COPD? I have never dispensed an rx for 360 vials of albuterol, that's 14+1/2 boxes. I actually think the OP did the correct thing. Give the patient some now so the therapy is not interrupted and then contact the physician for clarification. Anyone who thinks the order is 360 vials is making an assumption. That usually does not work out well.

 

[CynicalIntern]

No, the order has to be appropriate. Why would anybody use nebulized albuterol qid every day for 90 days? What is the diagnosis? Asthma? COPD? I have never dispensed an rx for 360 vials of albuterol, that's 14+1/2 boxes. I actually think the OP did the correct thing. Give the patient some now so the therapy is not interrupted and then contact the physician for clarification. Anyone who thinks the order is 360 vials is making an assumption. That usually does not work out well.

I have, quite frequently, and the pharmacist I worked under at that point, while a little irate at the wasted medicine, didn't hesitate to dispense it. The MD essentially gave them a maximum they could possibly use under his directions, and while it will probably (definitely) last them longer than 3 months, there's no way that you can assertively know that. There's no reason to assume that the physician went through the trouble of multiplying extra math into his order when he has no need to, and while it's your right as a pharmacist to call the physician for a clarification, when the patient said up front that it's supposed to be for 3 months and the number given logically can be a 3 month supply if you don't do any extra possibly unnecessary math, this seems like the kind of case that will make a physician irate for you bothering them, or a "medical assistant" who just thinks you're incompetent.

 

[Sparda29]

No, the order has to be appropriate. Why would anybody use nebulized albuterol qid every day for 90 days? What is the diagnosis? Asthma? COPD? I have never dispensed an rx for 360 vials of albuterol, that's 14+1/2 boxes. I actually think the OP did the correct thing. Give the patient some now so the therapy is not interrupted and then contact the physician for clarification. Anyone who thinks the order is 360 vials is making an assumption. That usually does not work out well.

I dunno, I find that some pharmacists agree with me on things like this while others disagree. When you're in a situation when the quantity is not really specified and you don't have time to contact the prescriber, I'd rather give the patient an excess, especially on stuff like creams and whatnot.

For example, I see this all the time. Spectazole cream, dispense 100 grams. It does not come in 100 grams, the biggest tube is 85 grams. Personally, I'd give the patient 2 tubes, thus 170 grams (70 grams excess), rather than 1 tube, thus 85 grams (15 grams deficit). From a customer service point of view, they might bitch when they see that you gave them a smaller quantity than what was on the prescription, they aren't gonna bitch about receiving an excess.

 

[MountainPharmD]

No, the order has to be appropriate. Why would anybody use nebulized albuterol qid every day for 90 days? What is the diagnosis? Asthma? COPD? I have never dispensed an rx for 360 vials of albuterol, that's 14+1/2 boxes. I actually think the OP did the correct thing. Give the patient some now so the therapy is not interrupted and then contact the physician for clarification. Anyone who thinks the order is 360 vials is making an assumption. That usually does not work out well.

Weather or not the order is appropriate has nothing to do with the OP's original question. This was posted by a tech/student. It is up to the pharmacist to determine if the order is appropriate. The tech/student received a prescription for nebulizer vials that had a quantity of 360. There are no assumptions here. 360 was clearly written on the prescription, 360 is 360. The OP's original question was about billing for nebulizer vials. I fear the OP is still confused as to the billed quantity in the computer verse the dispense quantity on the prescription. As an aside I have several end stage COPD patients who get a 90 supply of Albuterol and Ipratropium. Nothing unusual or strange about this prescription.

 

[Old Timer]

Weather or not the order is appropriate has nothing to do with the OP's original question. This was posted by a tech/student. It is up to the pharmacist to determine if the order is appropriate. The tech/student received a prescription for nebulizer vials that had a quantity of 360. There are no assumptions here. 360 was clearly written on the prescription, 360 is 360. The OP's original question was about billing for nebulizer vials. I fear the OP is still confused as to the billed quantity in the computer verse the dispense quantity on the prescription. As an aside I have several end stage COPD patients who get a 90 supply of Albuterol and Ipratropium. Nothing unusual or strange about this prescription.

I disagree with you completely. 360 what? You are assuming vials and there is no evidence of that based on what she posted. I agree COPD patients get a large quantity of Duoneb but there is no human who should be using a nebulized albuterol qid for 90 days. No indication at all. I would not dispense this w/o calling the doctor and maybe not even then. There are no guidelines to back you up, this is either inappropriate treatment or an attempt do defraud the insurance company. She is not confused at all. The only problem I have is she assumed ml's the same way you assumed vials. Sorry, but with nothing after the 360, her assumption is just as and based on treatment guidelines maybe even more valid than your assumption. But either way, this is just an assumption.

 

[Farmercyst]

While I've never dispensed 360 vials of albuterol nebulizer soln, the sig seems to indicate that's what should be dispensed. Typically the units would carry through on the prescription. If the rx indicates to dispense 360 (unitless) but the sig is in vials (as opposed to mLs) the natural assumption would be to dispense that many vials. Granted, it would be an assumption, so I agree a call should be made to the practitioner to clarify as 360 vials seems excessive.

 

[spacecowgirl]

Lastly, I'm quite disappointed this is how professionals treat one another in this career. This is why so many students would rather just not post, because for some reason, every conversation ends up in the: "I know more than you do, because I have been around longer." That's great you've been around longer, it's just that I wasn't born earlier. But that should not discourage me from posting or sharing a point of view, and colleagues should share their experiences. Yes, I am a student. I am here to learn. If you don't want to teach me anything, then that's okay.

I think Mountain posted very nicely the first time but you continued to argue about it. What I have noticed is students arguing with people who have clearly been around a lot longer. Students get defensive with lengthy explanations and really, that helps no one - not you, not the pharmacist, not the patient. I see that here and I see it IRL. I'm not saying it's appropriate to get sarcastic, but please students, just listen and think, don't get immediately defensive. I'm not saying don't share your thoughts, especially if you think patient safety is at risk. But don't split hairs just to be right.

My 2 cents.

 

[Doctor M]

Please, what doctor writes for ml's? Every rx i have seen the NP or Doc writes for vials. MountainPharmD has explained his reasoning and i agree with it. Ultimately, its up to the Rph on duty and I would dispense the number of vials. I have never seen an rx for Albuterol solution #25 ml's. I mean, really? Call me arrogant, but this is silly...And students, dont be so sensitive and defensive...Your reading too much into this...And if your that worried about an audit, then call the doctor...I just document what i dispensed, let the pt be on their way and then i will let the physician know what I did. I use my professional judgment...

Dr. M

 

[Farmercyst]

Please, what doctor writes for ml's? Every rx i have seen the NP or Doc writes for vials. MountainPharmD has explained his reasoning and i agree with it. Ultimately, its up to the Rph on duty and I would dispense the number of vials. I have never seen an rx for Albuterol solution #25 ml's. I mean, really? Call me arrogant, but this is silly...And students, dont be so sensitive and defensive...Your reading too much into this...And if your that worried about an audit, then call the doctor...I just document what i dispensed, let the pt be on their way and then i will let the physician know what I did. I use my professional judgment...

Dr. M

I've only dispensed the inhalation solution a handful of times, but it's always been written in mLs, not vials. Granted, always in this case means 5-6, but still...(and you wouldn't see 25 cuz it's multiples of 3)

 

[Doctor M]

I've only dispensed the inhalation solution a handful of times, but it's always been written in mLs, not vials. Granted, always in this case means 5-6, but still...(and you wouldn't see 25 cuz it's multiples of 3)

lol, yeah, the prescriber knows it comes in multiples of three... Ive never seen it written in mls. Ive only seen vials and number of boxes. Have u ever seen duoneb written as dispense as 62.5 mls? And albuterol sln comes in different size boxes, 25 vials and 30 vials...This argument is silly...Dispense the vials if there is nothing stating otherwise...