Drug Topics - March 10, 2008 - (Page 53) www.drugtopics.com MARCH 10, 2008 DRUG TOPICS 53 Special Report How to make best use of healthcare and billing codes April S. Brown, Pharm.D., R.Ph. harmacists have triumphed during the past few years in gaining provider status for certain services under various third-party payers. Having provider status, however, means that pharmacists must now learn how to bill various payers for these specific types of products and services. Although there are many articles which highlight various reimbursable services themselves, not much explanation is given to the myriad of codes that pharmacists will encounter (either directly or behind the scenes) when submitting for payment. This article is designed to help guide pharmacists through the jumble of CPT codes, HCPCS codes, taxonomy codes, modifier codes, POS codes, diagnosis codes, and other codes relevant to billing. or changing practice or group affiliation. All providers, including pharmacists, who bill thirdparty payers (federal, state, or private) for any goods or services are required to obtain and use NPI numbers on any HIPAA-covered transaction (claim) as of May 23, 2007. Many pharmacists are not aware that they are also required to use their NPI number if they work under a protocol or collaborative practice arrangement in which they are named as a referring provider (also called a secondary provider) to another healthcare provider (a laboratory, a specialist, etc.). In addition, those pharmacists who plan to bill for services, such as immunizations, CLIA testing services, or medication therapy management, independent of an employer, also must obtain an NPI number to receive claim reimbursement. As a point National Provider Identification for further clarification, the Centers for Medicare & (NPI) Medicaid Services considers a primary provider to be One new landmark change in ‘coding’ requirements for any billing, pay-to, or rendering provider. All other all providers is the move to National Provider Identifica- providers (including referring, ordering, supervising, fation (NPI) numbers. These mandates, as provisions of cility, care plan oversight, purchase service, attending, the Health Insurance Portability and Accountability Act operating, and other providers) are considered to be sec(HIPAA) 1996, required the development of ‘standard’ ondary providers. national identifier numbers for all providers, health A large number of providers did not meet the May plans, and employers. The intent was to improve the ef- 2007 NPI deadline. Therefore, CMS developed an NPI ficiency of electronic data interContingency Plan which extended the DT CAPSULE DT CAPSULE change—as more than five billion date for providers to begin using NPI claims are processed by healthcare innumbers. Providers must be aware, surers in the United States each year. If pharmacists are however, that the contingency plan Prior to this requirement, claims syshas the following rigid implementatems were burdened with the growing to advance as ‘true’ tion dates: amount of information and crosswalk •January 1, 2008—NPI numbers systems needed for successful claims providers, they must be used on 836I and UB04 adjudication. Before the use of NPI claim forms to identify the primary must learn the numbers, every provider was required provider or the claim will be rejected. to have a unique ID number which professional Secondary providers can be identified corresponded to every payer he or she with NPI or NPI and legacy combinabilled to. tion. coding systems. Multiply the number of providers •March 3, 2008—NPI numbers and provider types in the United States by the number must be used on 837P and CMS-1500 claim forms of private, state, and federal payers, then again by the (these forms are most relevant to pharmacists who bill number of claims submitted, and it becomes clear why Medicare for MTM, vaccinations, and CLIA tests) to the need for NPI numbers came about. Under the new identify the primary provider or the claim will be rejectsystem, each provider is assigned a single NPI number ed. Secondary providers can be identified with NPI or to use with all payers. Each provider’s NPI number stays NPI and legacy combination. the same throughout the practitioner’s life, irrespective •May 23, 2008—CMS will lift the NPI Contingency of personal or professional relocation, advancing degree, Plan and only NPI numbers will be accepted for all P http://www.drugtopics.com
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