Learning Objectives Pharmacist Pharmacy Technician 1. Describe - PDF document

9/29/2016 Revenue Opportunities and Documentation Requirements for Ambulatory Care Pharmacist Clinical Services Melanie A. Dodd, Pharm.D., Ph.C., BCPS Vice-Chair, Department of Pharmacy Practice and Administrative Sciences College of Pharmacy, The University of New Mexico Learning Objectives Pharmacist Pharmacy Technician 1. Describe three CMS billing 1. List three CMS billing opportunities for clinical opportunities for clinical services provided by services provided by pharmacists in an pharmacists in an AC ambulatory care (AC) practice setting. practice setting. 2. Describe the CMS ‘incident 2. List the CMS ‘incident to’ to’ physician criteria physician criteria. pharmacists must adhere to in order for services to be eligible for billing. 3. Outline the documentation 3. Describe the potential role of requirements for various pharmacist technicians and pharmacist billing scenarios. other staff in supporting AC pharmacist clinical services. 1

9/29/2016 What is your current practice setting? A. Community pharmacy B. Ambulatory clinic within health- system C. Inpatient hospital, but looking to expand to ambulatory care D. Managed care E. Other Which Statement Reflects Your Pharmacist Billing Knowledge Best? A. This is all new to me! B. I have some knowledge of billing, but interested in learning more. C. I understand how to bill incident to physician, annual wellness visits, transitional care management, diabetes self management education/training, and chronic care management. 2

9/29/2016 Are you currently billing for ambulatory care pharmacist services? A. Yes, I am currently billing Medicare, Medicaid, or other insurance payers B. Yes, I bill patients directly C. No, but my services are paid for by value added services within my organization D. No, but I’d like to learn how ASHP Practice Advancement Initiative (formerly Pharmacy Practice Model Initiative (PPMI)) Ambulatory Care Summit Recommendations (AJHP 2014:71:1390-1.) • Defining Ambulatory Care Pharmacy Practice (1.1-1.5) • Patient Care Delivery and Integration (2.1-2.8) • Sustainable Business Models (3.1-3.5) • Outcomes Evaluation (4.1-4.7) • PAI Ambulatory Care and Hospital Self-assessment • http://www.ashpmedia.org/pai/ 3

9/29/2016 Sustainable Business Models (PAI 3.1-3.5) • 3.1 Pharmacists must be recognized as healthcare providers • 3.2 The value proposition for pharmacists who provide AC services must be articulated and promoted for internal and external stakeholders • 3.3 Technology solutions must be able to attribute pharmacists’ interventions toward achieving standard measures that validate patient and population-based outcomes in AC settings Sustainable Business Models (PAI 3.1-3.5) • 3.4 Services provided by pharmacists who provide AC services should achieve a set of quality and costs measures, be supported by payment model(s), and be valued by demonstrated improvements in patient outcomes • 3.5 Pharmacy and other AC leaders should continuously identify and evaluate solutions to market and deliver financially viable pharmacists' services to patients and other healthcare stakeholders. 4

9/29/2016 Recognized Provider Status Health care professional who conducts patient visits and bills for their services under their own provider number National Provider Identifier (NPI) Pharmacists must have an NPI if want to bill as a provider Free online application (CMS form 10114) https://www.cms.gov/Medicare/CMS-Forms/CMS- Forms/downloads/CMS10114.pdf NPI gives pharmacists a national provider number, but not recognized national provider status 5

9/29/2016 National Pharmacist Provider Status • Title XVIII Social Security Act • Providers recognized by Medicare Part B • House of Representatives Bill 592 and Senate Bill 314 • Pharmacy and Medically Underserved Areas Enhancement Act • Medicare Part D, varies by PDP • Commercial payers, limited to individual contracts • Self-insured employers, limited to individual contracts New Mexico Provider Status • Pharmacist clinicians • New Mexico Medicaid Fee-for-Service • Provider type 320 • Bill using Evaluation and Management (E&M) codes under physician • Patient-centered medical homes • Chapter 43 of 2010 New Mexico laws • Expanded eligibility for recognition as offering medical homes • Pharmacist Clinicians 6

9/29/2016 What are you billing opportunities? (See handout) What is your setting? 1. • Physician-based clinic (private practice) • Physician outpatient clinic that is NOT financially tied to a hospital (the physician group owns the practice under a separate business tax ID number) • Hospital-based outpatient clinic • Physician outpatient clinic that is financially tied to a hospital (one tax ID number) • Community pharmacy What are your credentials? 2. • Pharmacist clinician • Certified diabetes educator (CDE) Practice CPT billing Setting 2016 Medicare Billing Options codes PB=physician based Pay ment New Mexico ll HB=hospital based Diabetes self-management G0108 (individual visit) all G0108 = $52.07 training (DSMT) G0109 (group visit) G0109 = $13.97 CLIA-Waived Lab variable per POC test all fixed per CPT code Medication Therapy 99605, 99606, 99607 pharmacy, employer, variable per payer Management (MTM) health plan Incident to physician: Office 99211 = $19.03 visit in a PHYSICIAN-BASED 99212 = $41.88 (aka, non-hospital) clinic 99211-99215 (PB) PB 99213 = $70.87 99214 = $104.59 99215 = $141.34 Incident to physician: Office visit in a HOSPITAL-BASED G0463 (HB) HB G0463 = $102.12 outpatient clinic Incident to physician: 99496 (within 7d D/C) 99496 = $224.70 (PB) Transitional Care Management 99495 (within 14d D/C) PB & HB $158.56 (HB) (TCM) with RPh part of team 99495 = $159.26(PB) $109.58 (HB) CMS Annual Wellness Visit G0438 PB & HB PB/HB: G0438 = $166.95 (AWV) (initial,once/lifetime) PB/HB: G0439 = $112.81 G0439 (subseq, annual) Chronic Care Management 99490 PB & HB PB: $39.63 monthly (CCM) (20 minutes/month) HB: $31.07monthly 7

9/29/2016 DOCUMENTATION REQUIREMENTS Documentation Requirements • Document each and every patient encounter. • Be accurate and thorough in the documentation as the medical record becomes a legal document. • There is no requirement for the physician or supervising provider to sign off on all Pharmacist’s service. • Best Practice would include a review by the pharmacist of other health care providers documentation, including the primary care provider or other specialties. (Be aware of your quality improvement) • The documentation should also include recording of phone calls, letters, faxes, etc. to/with/from the patient’s physician or patient communicating the services. 8

9/29/2016 Documentation Requirements (continued) • Progress notes must substantiate the service performed (level of care) and be signed by the Pharmacist. • Documentation should show a review of the pertinent patient medical history, medication profile, interventions, recommendations for optimizing medication therapy, referrals, treatment compliance, and communications with other healthcare professionals. • Documentation should show any administrative functions (including patient and family communications) relative to the patient’s care. Ex: Use of translator or communication with care taker or family member who is managing the patient’s medications, prepares meals, provides transportation. • Any follow-up care planned should be recorded in the medical record. MEDICATION THERAPY MANAGEMENT (MTM) 9