Monday, March 31, 2003

HIPAA transactions standards

Q. I understand that DHHS adopted
a final rule on February 20th addressing the HIPAA transaction standards and code sets for the submission of drug claims. I operate a closed-door respiratory pharmacy and submit claims for nebulizer drugs to the DMERCs. What does this final rule mean to me?

A.In essence, the rule means that effective October 16, 2003 (or possibly earlier if you did not file for a transaction standards compliance extension), you will have to submit drug claims to the DMERCs using National Drug Codes (NDC) rather than the current HCPCS codes. Additionally, the claims submitted will have to comply with the National Council for Prescription Drug Programs (NCPDP) Telecommunication Guide Version 5.1 claim format.

The final rule published at 68 F.R. 8381 states that the NDC code set will be the standard code set for claims for drugs and biologics submitted by retail pharmacies. The NDC code set is not being adopted as a standard for non-retail pharmacy drug transactions (i.e. professional, institutional, or dental drug claims.)

In case you are thinking that your operation is not a retail pharmacy, and therefore not subject to these standards, CMS has decided otherwise. CMS Transmittal B-03-012, dated February 7, 2003, states “[f]or claims processing purposes, CMS considers any entity billing the DMERCs for a drug to be a retail pharmacy.” Additionally, this transmittal makes it clear that the NCPDP format and NDC code standards will apply not only to electronic claims, but to paper claims as well.

Lisa Smith is a healthcare attorney with Brown & Fortunato. Reach her at 830-896-0018