Managed Care - December 2008 - (Page 16)

New electronic transaction standards for pharmacy being prepared.” An example of the harmacy directors at health plans impact on the pharmacy industry is need to become versed in a numthat since the conversion from ICD-9 ber of proposed changes in coding. In to ICD-10 will create a one-to-many addition to the ICD-10 implementarelationship in many situations, the tion, the Centers for Medicare and pharmacy providers will not be able Medicaid Services has proposed the to readily cross-reference the two adoption of updated versions of stanformats but will have to contact the dards for electronic transactions origiphysicians to obtain the ICD-10 CM nally adopted in HIPAA legislation. value the physician has associated These standards were created by the with the patient. Standards Development OrganizaBoth the NCPDP tions, the National Council Telecommunication Stanfor Prescription Drug Prodard version 5.1 and the grams (NCPDP), and ASC more current version D.0 X12N. are capable of accepting Patsy McElroy, the manICD-10 submissions. ager of standards developCurrently, retail drug ment at the NCPDP, says pharmacy transactions that her organization subare formatted under the mitted comments on both NCPDP Telecommunicathe ICD-10 and the elec“We’re really tion Standard Implementronic transaction standards welcoming this,” tation Guide version 5.1. rules as proposed by CMS. Patsy McElroy, CMS has proposed man“There are two notices of of the National Council for Predating the use of version proposed rulemaking D.0 of the NCPDP (NPRMs) that were released scription Drug Telecommunication Stanin the Federal Register,” says Programs, says about ICD-10. dard. In one portion of the McElroy. “There’s one for NPRM, CMS has proposed the transaction standards, the adoption of both D.0 and the what is called HIPAA II, and then X12N 837 professional health care there’s one for the ICD-10. Each has claim for the billing of retail pharseparate implementation dates. The NCPDP Strategic National Implemen- macy supplies and professional services. tation Process (SNIP) Committee CMS wants the NCPDP Telescripted the NCPDP response to communication Standard version both NPRMs.” D.0 and the X12N HIPAA-named “Pharmacists submitting an ICD10 on a claim is infrequent, but could standards to be launched by April 1, 2010. NCPDP has recommended that be more prevalent for billing of a the regulatory compliance date for professional service,” says McElroy. D.0 be effective July 1, 2011. In an “But the payers are maintaining the Oct. 10 letter to CMS, Lynne ICD-9 in their patient profile systems Gilbertson, NCPDP’s vice president for circumstances such as priorfor standards development, warns: authorization requirements.” The official NCPDP response to • “Millions of patients could experiHHS states, “The pharmacy industry ence a disruption of service if the currently utilizes diagnosis codes new D.0 software is not working (ICD-9-CM) and relies on medical on the compliance date and the providers to supply these codes. previous version is not allowed. Therefore the pharmacy industry • “Patients may be asked to pay cannot implement the ICD-10-CM cash until the pharmacy can verify codes prior to the medical industry P • • their eligibility and financial responsibility. “Patients may have to wait to receive their prescription while the pharmacy attempts to obtain information from their plan sponsor/processor. “Incorrect copays/coinsurance and deductibles may be collected if the software is not working properly. This will result in an increase of adjustments and patient grievances being filed.” Aside from the deadline concerns, McElroy says that NCPDP very much favors the CMS proposal to move to new and more current versions of the HIPAA-named standards. “We’re really welcoming this,” says McElroy. “We just have to make sure that there are not any assumptions made as to when the industry is ready or not. Part of our comments back to CMS was that we felt that their implementation time line was a little aggressive.” Medicare Advantage When the new pharmacy coding standards are launched, everyone should notice an improvement. That’s especially true for pharmacy directors at Medicare Advantage plans that offer prescription coverage. “When Medicare Part D was mandated, the standards could not be updated to accommodate processing changes due to HIPAA requirements,” says McElroy. “We were basically required to address some of those changes by using structured messages in free text data elements, which is problematic for some payers and providers. “The Telecommunication Standard version D.0 incorporates the data elements necessary to support Medicare Part D processes. Health plans will certainly benefit because we have enhanced greatly the coordination of benefits processing.” 16 MANAGED CARE / DECEMBER 2008

Table of Contents Feed for the Digital Edition of Managed Care - December 2008

Managed Care - December 2008 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor ICD-10 Offers Huge Opportunity, Challenge Part D at a Crossroads Plans Can Weather the Financial Crisis DM vs. Medical Home? Tackle Prediabetes Reasonable Approach to Morning Sickness Formulary Files Tomorrow's Medicine Outlook

Managed Care - December 2008

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