New NCPDP Standards Activity: Claims, SCRIPT, MTM

Monday, August 28, 2017

Marsha K. Millonig, MBA, BPharm

While some of us may find the whole topic of standards development dry and tedious, we should appreciate the work of our colleagues who spend countless hours trying to improve the electronic exchange of information that is fundamental to our practice.

The National Council of Prescription Drug Programs, known as NCPDP, is the standards development organization that focuses on building transactions to support the pharmacy profession. The organization has been active recently, updating many of its standards to help us streamline and improve pharmacy processes.

Claims Transactions

We’re all familiar with the claim transaction; we’ve been using it in one form or another since the early 1990s. This was built off of the original Universal Claim Form (UCF) which allowed pharmacies to submit the same basic information to any third-party payer in order to be paid for a prescription claim. The claim transaction contained sections for pharmacy information, patient details, the drug, quantity, days’ supply, and prescriber information. That was all that was needed, and it fit on a form that was about 3 x 8 inches. Payment would follow in a few weeks … or longer.

Fast forward to today: Claims are submitted and processed electronically in seconds. They include all of the original information, plus details about other payers, expanded pricing information, clinical information about the patient (DUR, diagnosis), prior authorization details, and even information needed to meet the requirements of various government programs, such as Medicare and Medicaid.

The NCPDP Telecommunications Standard is named under HIPAA. Since the inception of HIPAA, two versions have been used: 5.1 and now D.0. The industry is preparing to move to a new version — F.2 — once the regulatory process is complete.

This new version includes:

  • Updates for reporting of controlled and non-controlled substances
  • Enhancements to support claims for compounded products
  • Clarifications to various formulae
  • Numerous changes to support regulated programs parameters (i.e., Medicare, Medicaid, 340B)
  • Added fields and changes to some field names and/or sizes
  • Added support for REMS program information exchange
  • Many other changes to support industry needs

SCRIPT Standard

More recently developed, but still widely used, is the NCPDP SCRIPT Standard, which enables e-prescribing.

Today, on average, more than 75% of prescribers and 90% of pharmacies are engaged in e-prescribing. Much attention is currently being paid to the use of e-prescribing for controlled substances (EPCS), which is supported by the SCRIPT Standard. SCRIPT is named under the Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA.

It is anticipated that by the end of 2017, a rule will be proposed that will move the industry from the current named version (SCRIPT 10.6) to the most current published version (SCRIPT 2017071). The new version reflects changes brought forth over the past years. These changes support a range of business and clinical needs such as:

  • Improvements to electronic prior authorization (ePA) transactions
  • Wound care details
  • IV administration
  • Pharmacy dose titration
  • REMS messages
  • Enhancements to Cancel, Change, and RxFill messages to improve their usability
  • Expanded guidance for many of the fields and messages

If you haven’t already talked to your vendors about how they plan to implement the new version of both Telecommunications and SCRIPT, you’ll want to start the conversations soon. Ask them to explain all of the new features that will be included in each version of the standard and how they plan to make those available to you. Some vendors may focus on supporting only the features currently in use, making minimal changes. Others will wait to hear from customers as to what is important to them. For pharmacies, receiving a Cancel message from the prescriber can have countless benefits, from patient safety, to productivity improvements and better inventory management.

Medication Therapy Management

Getting less attention, but perhaps of greater importance in advancing the practice of pharmacy is the work that has been done to enable the exchange of Medication Therapy Management (MTM) service information. NCPDP and HL7 have worked together to develop structured ways of exchanging this information.

NCPDP’s Specialized Standard supports communicating to the pharmacy or other provider relevant clinical information about the patient, along with the type, frequency, and total number of MTM encounters requested/approved. This request can be sent by a payer, treating or prescribing physician, pharmacist, facility, and/or the patient or caregiver. It is recognized that the pharmacy or provider may need to obtain further information via other sources or transactions (such as medication history, diagnoses, problem lists, medical conditions, allergies, laboratory results). Some of this information may be contained in the attachment; however, this exchange is new to this industry and changes are expected based on feedback from implementers.

After the request is received and the services provided, a related documentation transaction is available to send information on services rendered, which can include clinical information, recommendations for therapy modifications, referrals, etc. Having a standard way to document services provided can only help pharmacists by establishing a mechanism that supports their claims for reimbursement.

So, as you can see, our colleagues in the standards development world have been busy, finding ways to help us improve our practice and demonstrate our value. Now is the time to figure out how you’ll take advantage of the new versions so that you can better serve your patients, improve your communications with prescribers, and maximize your revenue opportunities.

Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.

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