Last week, the big news about data standards coming out of HHS was its notice of proposed rulemaking on adopting the ICD-10 codes and the ACS X12 data transmission standards needed to carry them.
But HHS also gave notice it wants to adopt several new standards for electronic-prescription transactions and split the baby by proposing to adopt some new standards developed by the National Council for Prescription Drug Programs, while also promoting continued use of a guideline for one of the same transactions developed by the Accredited Standards Committee, or ACS.
According to the notice published in the Federal Register, HHS recognized that two standards have industry support for use in the same purposebilling pharmacy-related professional services and supplies. The NCPDP standard is its upgraded Version D.0. The other, by the ACS, is its X12 837. Currently, the Health Insurance Portability and Accountability Act of 1996, under its section for transactions and code sets, requires use of NCPDPs Version 5.1 standard for billing of retail pharmacy claims for items such as prescription drugs, but calls for X12 837 for billing of professional supplies, such as syringes, inhalers and nebulizers, and for services such as medication-therapy management.
HHS explained the conundrum thusly: Since publication of the transactions and code sets rule, (the final rule was implemented in August 2000) there has been ongoing debate in the industry about which is the appropriate standard for billing retail pharmacy supplies and professional services. These are often tied to a retail pharmacy claim for a prescription, such as insulin, ointments and inhaler solutions. For example, a patient could get a prescription and/or refill for insulin and the syringes. Under the current rule, pharmacies are expected to submit the insulin claim in real-time, using the NCPDP standard, and get immediate benefit coverage and co-pay insurance information. However, they must bill the prescription for the syringes with the X12 standard, which is typically a batch-billing process so the pharmacist would not get immediate notification of coverage and co-pay insurance information.
The debate escalated with the Medicare Part D program in 2006, HHS said. The National Association of Chain Drug Stores was pushing for a switch to the new NCPDP Version D.0. (The earlier NCPDP Version 5.1 in wide use for prescription-drug claims could not handle pharmacy-services claims, according to HHS, but the new Version D.0 could.) While the chain drugstores wanted to switch to a common family of standards, independent pharmacies, whose computer systems were set up to use X12 837, favored sticking with the ACS standard, HHS said.
In coming up with a compromise, HHS recognized a unique situationno other HIPAA transactions can be adequately supported by two implementation guides. HHS decided to allow the use of either the NCPDP or the ASC X12 standards. HHS said allowing either to be used we believe would accommodate prevailing business practices, ensure efficiency and prevent redundant costs. The plan would be the least disruptive to the industry, HHS said. HHS is seeking comment on the proposed rule, which includes an April 1, 2010 compliance deadline for use of the new pharmacy standards.
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