SIRA medication codes: guidance for coding

The Medication management in the NSW personal injury schemes: Better practice guide aims to minimise the potential harms associated with the use of medications in the NSW personal injury schemes (CTP and WC). This guidance is designed to assist insurers to apply the SIRA medication codes in their coding practice.

1. The codes

SIRA has set up medication codes to track the use of high risk medications and the use of the Pharmaceutical Benefits Scheme (PBS) for the supply of medicines.

2. Pharmaceutical Benefits Scheme

The Pharmaceutical Benefits Scheme (PBS), which is part of Australia’s broader National Medicines Policy, supports the safe and quality use of medicines and provides a built-in safety mechanism when dealing with high risk medications.

3. Pharmacy invoice

3.1. Invoices

SIRA recommends insurers ensure their systems pay pharmacy costs based on the pharmaceutical invoicing requirements found in Part 8 of the Guidelines for the Provision of Relevant Services (Health and Related Services). WC insurers should ensure they also keep in line with the invoicing Standard of Practice. Insurers should check the pharmacy provider's invoice complies with SIRA's invoicing requirements in Part 8 of the Guidelines for the Provision of Relevant Services (Health and Related Services).

Contact the pharmacist directly if the invoice does not comply with the requirements as this will make coding much easier. Pharmacy invoices and statements MUST contain the following information:

3.2. Reimbursements

Any claims for reimbursement of pharmacy costs should be accompanied by:

• a dispensary computer generated tax receipt for PBS and private (non-PBS) medications supplied for treatment of their compensable injury
• a dispensary receipt or a cash register receipt for over the counter and equipment items supplied for treatment of their compensable injury.

Request further information from the person or the pharmacy provider if the invoices or receipts (for example, a cash register receipt) have insufficient detail to identify the medication or item that was supplied to the person.

4. Coding rules

When a medicine can potentially be coded in more than one category, the following coding rules should be applied:

• Any opioid that is injectable should always be coded as PHS130: injectable opioid (also known as narcotics)
• Any opioid prescribed as part of a MATOD program set up by the general practitioner should always be coded as PHS140: opiate replacement therapy/medication assisted treatment of opioid dependency (MATOD)
• Z drugs (zolpidem, zopiclone and zaleplon) should always be coded as PHS230: non-PBS z drugs (z drugs are private only)
• All medicinal cannabis products, including over the counter, should always be coded PHS300: medicinal cannabis medications (cannabinoids)
• Any over the counter medicines related to the injury should always be coded PHS430: over the counter medications (excludes other purchases that are not medicines)

5. Coding process

5.1 Was the medicine prescribed through the PBS or privately?

The standardised invoice should either have a PBS number or indicate the medicine was prescribed ‘privately’ or ‘non-PBS’. Most pharmacy invoices will have two columns at the top labelled “PBS” and “Private”.

The PBS items will have a PBS code in the PBS column, generally a 5-6 alphanumeric code in the format of 4-5 numbers followed by a letter (eg. 1215Y). The private items will be identified in the Private column (see example below).

• Contact the pharmacy and request the standardised invoice information be put on invoices
• If the medicine is prescribed through the PBS, the code will be either:
  • Opioids (PHS100)
  • Benzodiazepines (PHS200)
  • All other medications (PHS400)
• If the medicine is prescribed privately, the code will be either:
  • Opioids (PHS110 or PHS120)
  • Benzodiazepines (PHS210 or PHS220)
  • All other medications (PHS410 or PHS420)

5.1.1 Identify if the medication prescribed privately is available on the PBS.

Search the PBS website https://www.pbs.gov.au/pbs/home to identify if the medicine prescribed privately is available on the PBS. Prescription medicines not available on the PBS should be identified as ‘private’ on the standardised invoice.

If the medicine does not come up with an exact match in the PBS search results, either by active ingredient or brand name, then it is not available on the PBS.

• Type the name of the medicine by active ingredient or brand name as it appears on the pharmacy invoice in the ‘PBS medicine search’ box at the top right-hand corner of the PBS home page
• The search findings will list medicines that are found on the PBS
• Check the details of the medicine on the invoice match exactly to the search findings in terms of name, form and strength, and pack size as each variation of the medicine has a separate PBS number
• If you find an exact match, then the medicine is available on the PBS (you can click on the exact match to find the PBS number)
  • The unique PBS code for that specific medication is found on the left-hand side column of the table under Code and prescriber
• If you do not find an exact match, then the medicine is not available on the PBS
• Different brand names of the same active ingredient in the same amount will have the same PBS number
  • For example, the PBS code for oxycodone 5mg tablets x 20 is 2622B, and the brands listed with this number are Endone, Mayne Pharma Oxycodone IR and Oxycodone Aspen.
• If the medicine is available through the PBS but was prescribed privately, the code will be either:
  • Opioids (PHS110)
  • Benzodiazepines (PHS210)
  • All other medications (PHS410)
• If the medicine is not available through the PBS, the code will be either:
  • Opioids (PHS120)
  • Benzodiazepines (PHS220)
  • z drugs (PHS230)
  • All other prescription medications (PHS420)
  • Over the counter medications (PHS430)

5.2 Is this a high risk medication?

5.2.1 Identify the active ingredient of the medicine

Knowing the active ingredient allows you to determine if the medicine is from one of the high risk medication groups. The NPS MedicineWise website is an independent, not for profit, evidence based and consumer centred organisation. Their Medicine Finder tool is a reputable source of information on medicines.

• https://www.nps.org.au/medicine-finder

5.2.2  How to search for the active ingredient

• Go to https://www.nps.org.au/medicine-finder
• Type the name of the medicine by active ingredient or brand name as it appears on the pharmacy invoice
• Highlight the CMI search for Consumer Medical Information
• Click search – the results will show the name of the brand and the name of the active ingredient
• Click the name to take you to the details of the medication
• Scroll down to the section what is (medication name) used for which will tell you the group of medicines the medication belongs to. For the purposes of SIRA coding, we are looking for:
  • opioids, which may also be classified as narcotic analgesics
  • benzodiazepines
  • z drugs, refer only to three medications (zolpidem, zopiclone and zaleplon)
  • medicinal cannabis, which may also be classified as cannabinoids

If the medication is a high risk medication, the code will be either:

• opioids (PHS100, PHS110, PHS120)
• injectable opioids (PHS130)
• MATOD (PHS140)
• benzodiazepines (PHS200, PHS210, PHS220)
• z drugs (PHS230) or
• medicinal cannabis (PHS300).

If the medication is NOT from one of the high risk medication groups, it should always be given a code from the all other medications category (PHS400, PHS410, PHS420 or PHS430).

5.3  Commonly prescribed high risk medications for motor vehicle or work-related injuries

5.4  Compounded products and other common terms that may appear on pharmacy invoices