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TRANSCRIPT
The Practice of Pharmacy’s Future: Provider Status
Andrew Hibbard PharmD, BCACP, BCGP
Zachary Rosko PharmD, BCPS, CDE
United States Public Health Service USPHS Report to the US Surgeon General 2011
“One of the most evidence-based decisions to improve the health system is to maximize the expertise and scope of the pharmacist and minimize expansion barriers of an already existing and successful health care delivery model.”
Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011.
Pharmacist State Provider Status Bills 2019
• In 2019’s Legislative session: • 147 state provider status bills for pharmacist
• 39 states had bill introduced
• 22 bills in 18 states where signed into law as of 06/10/2019
• National Alliance of State Pharmacy Associations Provider Status Bill Categories:
• Scope of practice bills
• Designation of pharmacist’s as providers
• Payment for pharmacist-provided patient care services
Provider Status: State Level • Domain one:
• Provider designation • Is there language that identifies pharmacists as providers in state code?
• Domain two:
• Scope of practice should align with education and training that pharmacists receive today • Examples: Post-diagnostic disease state management, medication therapy
management, prescriptive authority, diagnostic authority, state-wide protocols..ect
• Domain three: • Reimbursement for cognitive services • Payment should not be attached to the product being dispensed • Payment should be a covered health service • Payment for the service should not solely be put on the consumer/member • Payment should not be limited by place of service (POS) with some exceptions
Pharmacist Provider Status
Providing clinical services that are compensated with in a fee-for-service construct Credentialed network provider within a health plans major medical benefit
=
Prescriptive Authority
“Scope Creep” Dispensing Dependent
Payment Extra Training or
Certification
≠ Pharmacist Provider Status
The Oregon Trail
careoregon.org
careoregon.org
CareOregon is…
Founded in 1993, CareOregon is a
nonprofit, community benefit
company serving over 300,000
Medicaid and Medicare members.
Our mission is building individual
well-being and community health
through shared learning and
innovation. Our vision is healthy
communities for all individuals,
regardless of income or social
circumstances.
careoregon.org
The Pharmacist Collaborative: Mission & History • Established to encourage peer-to-peer support &
identify best practices for clinic pharmacists
• Core group: Old Town Clinic, OHSU Richmond, Legacy Emanuel/Good Sam, Multnomah Co., Virginia Garcia
• First meeting Mar 2012 & continues to meet monthly
• Funded a pilot grant for clinical pharmacy services Jan –Dec 2013
• Goal: provide clinical pharmacy services to high acuity patients in order to ensure effective drug therapy management.
• Focus on contracting & credentialing for pharmacist
fee-for-service (FFS) billing 20152018
2012
“Medication trauma is medication
complexity and lack of coordination that
overwhelms the patient, caregivers and
providers resources creating fear,
confusion, error which leads to poor
adherence, compliance and outcomes.”
Jim Slater, Pharm.D. VP of Pharmacy CareOregon
careoregon.org
Clinic Pharmacy Partners • LOA with 5 clinics:
• Central City Concern
• Legacy
• MCHD
• OHSU Richmond
• Virginia Garcia
• Embedded pharmacists:
• Clackamas County Health Dept.
• Neighborhood Health Center
2015
careoregon.org
Where We Started • 2015: Clinic Embedded Pharmacist Pilot
• 1 Full Time Clinical Pharmacist
• 1 Part Time PGY2 Ambulatory Care Pharmacy Resident
• 1 Part Time PGY1 Managed Care Pharmacy Resident
Funded by the health plan and embedded in an existing Federally Qualified Health Center with a large density of complex health plan members.
Goals: Clinical Pharmacists to meet 1 on 1 with members and perform medication reviews to coordinate medication use. Determine if billing for clinical services can sustain integrated clinical pharmacy.
Objectives:
-Track change in DTCR Score
-Track change in RX spend per member/year.
-Collect 50% of pharmacist salary in reimbursement for billed encounters.
Medical Documentation Basics
Medical Documentation Basics: Background • Medical documentation and record keeping is integral to good professional
practice and the delivery of health care • Electronic or paper records
• Enables continuity of care and enhance communication across healthcare professionals
• Clinical records should be updated by all members of the patients care team including pharmacists
• Continuity in clinical notes is of vital importance to patient care!
• A structured way to record your interactions with your patients
• Include any clinically substantive discussions related to the patients new or existing problems or routine care
• “The duty to share information can be as important as the duty to protect patient confidentiality” Caldicott NHS
Documentation Tips Always Document What You did and Why You Did It!
Documentation Tips If you did not write it down, it did not happen.
Documentation Tips Every entry should be timed, dated, and signed
Documentation Tips Thorough, accurate, objective, professional, factual, and legible to all readers
Medical Documentation Basics • Clinical Notes Should Include
• Patient demographics
• Reason for current visit
• Scope of examination
• Positive exam findings
• Pertinent negative exam findings
• Key abnormal test findings
• Diagnosis or impression
• Clear management plan and agreed actions
• Treatment details and future recommendations
• Medications administered, prescribed, renewed
• Drug allergies
• Instruction to the patient (oral & written)
• Clinical justification
• Recommended follow up date
Poor Clinical Records • Misinform healthcare professionals, and
patients • Increase medical legal risks and liability • Waste health care resources • Jeopardize patient care • Lead to serious incidents • Reduce revenue gained • Increase revenue lost • Can have significant legal implications
Medical Documentation Basics: Overview • Common Progress Note Formats
• Subjective, Objective, Assessment, and Plan • Subjective, Objective, Assessment, and Recommendation • Subjective, Objective, Assessment, Plan, and Recommendation • Situation, Background, Assessment, and Recommendation
• A structured way to record your interactions with your patients • Include any clinically substantive discussions related to the patients new
or existing problems or routine care
• There potential for many readers of a patient’s chart including: • Other providers • Insurance Claims Administrators • State board peer reviews • Attorneys • The patient
• Progress notes should: • Be clear and succinct • Readable and transparent devoid of jargon and obscure abbreviations • Your clinical reasoning should be explicit to the naivest readers
SOAP Note
S - Subjective Data: • Descriptive information that is unsupported by diagnostic tests or procedures
• Generally obtained from the patient
O - Objective Data: • Physical examination, labs, procedures, imaging studies
A - Assessment: • What the practitioner thinks the patients problems are
• Based on subjective and objective data
P - Plan: • Ordering of medications, labs, procedures, imaging
SOAP Note
S - Subjective: • Chief complaint (cc)
• History of Presenting Illness (HPI)
• Past medical history (PMH)
• Family History (FH)
• Social (SH)
• Medications
• Allergies
• Review of Systems (ROS)
History of Present Illness (HPI) PPQRSSTA • Precipitating (What caused the condition?)
• Setting – what the patient was doing when the symptoms occurred
• Palliative factors (What has provided relief?) • Things that make the symptoms better or worse
• Quality (Describe the condition) • Specific descriptive terms of symptoms (sharp pain, black tarry stools)
• Radiation (Is it localized? Where else does it occur?) • Usually used when assessing pain
• Site/Severity (Where is the problem? How severe is it?) • Location – precise area of symptoms • Mild, moderate, severe
• Temporal factors (When did the problem begin? How often does it occur?)
• Timing - Onset, duration, frequency of symptoms
• Associated symptoms/ROS (Are there any other symptoms?)
• Ask ROS questions that relate to the organ system(s) and problem associated with the chief complaint
History of Present Illness (HPI) PPQRSSTA
Application
“What is the best medicine you have out here for headaches?”
CC:
Headache for the last 2 hours
HPI
John is a 35 yo financial analyst at a local hospital. He has had a headache for the last 2 hours and would like to take an OTC for relief. He took 325mg of APAP 1/2 hour ago with no relief
PMH
Exercise induced asthma
GERD
SH
Lifetime non-smoker, Coffee: ~1/2 pot/day
(none today, late for work)
Medications
Albuterol MDI prn
Prilosec OTC 20mg qam
APAP 325mg PRN
Drug Allergies/ADR
Penicillin (hives)
Codeine (nausea)
ROS
Throbbing behind eyes, Gets headache rarely
SOAP Note
S - Subjective Data: • Descriptive information that is unsupported by diagnostic tests or procedures
• Generally obtained from the patient
O - Objective Data: • Physical examination, labs, procedures, imaging studies
A - Assessment: • What the practitioner thinks the patients problems are
• Based on subjective and objective data
P - Plan: • Ordering of medications, labs, procedures, imaging
SOAP Note
O - Objective • Vital signs
• Physical Exam Findings
• Reported or reviewed lab Results
• Imaging results
• Procedures
• Risk Factors
• Other diagnostic data
• Recognition and review of documentation of other clinicians
Pearl Do not put new orders in the objective section unless they have been resulted already
SOAP Note
S - Subjective Data: • Descriptive information that is unsupported by diagnostic tests or procedures
• Generally obtained from the patient
O - Objective Data: • Physical examination, labs, procedures, imaging studies
A - Assessment: • What the practitioner thinks the patients problems are
• Based on subjective and objective data
P - Plan: • Ordering of medications, labs, procedures, imaging
SOAP Note
A - Assessment • Diagnosis or differential diagnosis • Reasons for assessment • Conditions progression and status
• Improving, worsening, maintaining improvement, acuity patterns
• Medication compliance and tolerability • Problem (listed in order of importance) • Should justify treatment plan
• The synthesis of “subjective” and “objective” provides evidence to justify what you are going to do, and why your seeing the patient today
SOAP Note
S - Subjective Data: • Descriptive information that is unsupported by diagnostic tests or procedures
• Generally obtained from the patient
O - Objective Data: • Physical examination, labs, procedures, imaging studies
A - Assessment: • What the practitioner thinks the patient's problems are
• Based on subjective and objective data
P - Plan: • Ordering of medications, labs, procedures, imaging
SOAP Note
P - Plan • What testing is needed and rationale for choosing the test
• What next steps would be if results are positive or negative
• Therapy needed (Orders): medications, labs, imaging, procedures
• Referral to specialist(s) or additional provider(s) for consult
• Patient education, counseling
• Status/agreement of treatment plan progression
• The content under S_O_A_P headings should be consistent. It is appropriate move the headings around to streamline communication.
Medical Documentation Basics: Summary
Information provided by the patient. Tracking the course of the condition(s) you are treating. Changes in condition. Response to treatment. New symptoms. Condition effects
on daily living. Compliance to treatment plan. Medications.
Anything you observe or test in office during that visit demonstrating the medical necessity for treatment you rendered. General appearance, Demeanor, Physical Findings, Laboratory
Findings, Outcome Measurements.
Your reasoning for doing what you are doing. Identify the problems your managing (diagnosis). Indicate condition progression or status such as improving, worsening,
maintaining improvement, acuity patterns. Your S and O must support your assessment.
The treatment rendered during your visit or plan to render after the visit. Todays treatment. Patient education and instruction. Future care plans or referrals. Notes indicating test
results. Goals and Outcomes. When the patient is returning. Patient instructions
Show Me Charting
Patient Case #1: HG
2020 Case Recordings - Hermione Granger
Review of Chart
Physician’s Office Visit Note 9/2/19
Our Note (With EMR)
Our Note (Without EMR)
Patient Case #2: NL
2020 Case Recordings - Neville Longbottom
Practice Documenting
Breakout Session
Break
Documentation Debrief Keep your note for later!!!
Our Note (With EMR)
Introduction to E&M
Evaluation and Management Services
• General definition: • Coding set used to document the provision of health care services
(evaluation and/or management of health concern or problem) by physicians or other qualified healthcare professionals.
• Definitions established by AMA and published in the CPT coding manual.
• Identifies: • Patient Type
• Setting of Service
• Level of E/M Service Provided (Preventative or Problem Based; Level of Complexity)
• Purpose: • Establish a standard definition and weighting of the expenses
(practice, work and malpractice) of delivering health care services
• Used for the purposes of reimbursement
Setting of Service
Our Focus Today
• Office or other outpatient settings (Ex: FQHC, Medical Office, Pharmacy)
• Code Set 99201 - 99215
Other Settings
• Hospital Inpatient
• Hospital Observation
• Emergency Department
• Nursing Facility
• Assisted Living Facility
• Home Care
• Telephonic/Telemedicine
Patient Type New or Established?
Level of Evaluation and Management
• E/M services recognize seven components used in defining the level of E/M services
• History
• Examination
• Medical decision making
• Counseling
• Coordination of care
• Nature of presenting problem
• Time
Key components
Contributory factors
Proxy for total
work done
before, during,
and after the visit
Office and Outpatient E&M Levels: New Patient
• New patient requires all 3 key components (CPT: 99201-05):
• “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same specialty or subspecialty who belongs to the same group practice, within the last 3 years.”
• Nurse practitioner (NP), or physician assistant (PA) working with physicians within the same practice = same specialty/subspecialty
• Pharmacist working with physicians, NP, PA of the same practice AND specialty= same specialty/subspecialty
• Ex: Primary Care Pharmacist (BCPS or BCACP) is the same specialty as MD PCP.
• Ex: Clinical Pharmacy Specialist – Psychiatric Service (BCPP) is = PMHNP.
AMA CPT Coding Manual Quick Reference 99201-99205
Office and Outpatient E&M Levels: Established Patient
• Established patient requires 2/3 key components (CPT: 99211-15)
• “Patients who have received any professional service from a physician or other qualified healthcare practitioner of the same specialty/subspecialty within the last 3 years.”
• Probably the most relevant for pharmacist providing post diagnostic disease state management and working under a collaborative practice agreement
AMA CPT Coding Manual Quick Reference 99211-99215
Components #1 and #2 History and Exam
Components #1 and #2 History and Exam
Category and Extent of History Obtained (S)
• Problem focused • Chief complaint; brief h/o present illness or problem
• Expanded problem focused • Chief complaint; brief h/o present illness; problem pertinent system review
• Detailed • Chief complaint; extended h/o present illness; problem pertinent system
review extended to include review of a limited number of additional systems; pertinent past, family, and/or social history directly related to patient’s problems
• Comprehensive • Chief complaint; extended h/o present illness; review of systems that is
directly related to problem(s) identified in the HPI plus a review of all additional body systems; complete past, family, and social history
Three Domains of History (S)
Type of History CC HPI ROS PFSH
Problem Focused Required Brief N/A N/A
Expanded Problem Focuses
Required Brief Problem Pertinent N/A
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete
• Highly subjective and does not need to be in the correct order • Stick with a style and documentation standard you are comfortable with and align the
components to the service • Not all the patient’s history needs to be documented within every encounter • Perfectly acceptable to review ROS and PFSH from an earlier encounter and update only
pertinent differences to limit amount of re-documentation
Components Category
Extent
History of Present Illness (HPI) • Location: “Chest Pain”, sore “knee”
• Severity: Statement of degree of measurement regarding “how bad it is”, “improved status”, or “Fasting BS is 200”, or “can't sleep”
• Timing: When or at what frequency. “constant”, “morning”, “5 minutes in duration”
• Associated signs and symptoms: Any associated or secondary complaints related to the problem
• Modifying factor: Anything that makes the problem better or worse “medications”, “when standing”
• Context: What patient was doing, environmental factors/circumstances surrounding the compliant “while sleeping”, “slipped and fell”
• Duration: When did the complaint occur, duration of diagnosis “2 weeks ago”, “in childhood”
• Quality: Any characteristic about the problem and/or expresses an attribute “dull” ache, “sharp” pain, “metallic” taste
Review of System (ROS)
• Series of question seeking to spot signs and symptoms that the patient may be experiencing or has experienced
• Can be made by clinician or support staff
• Can be verbal or filled out by the patient (patient intake forms)
• Should help dictate the need for further physical examination, testing, or the possible affected medicines
• Review maybe about the system(s) directly related to the problem(s) identified in the HPI and additional system(s) that could be impacted
Review of System Cont. (ROS)
• Commonly misconceived as associated sign and symptoms • Can only get credit for 1 domain either HPI or ROS
• Must be medically necessary
• Example
“Patient states that their knee has been painful.
Denies any other MS complaint”.
ROS
HPI No double dipping.
Past, Family, and Social History (PFSH)
• Past History: Past experiences with illness, operations, injury, treatments, and medications
• Family History: Review of medical events in patient’s family, age at death, diseases, hereditary conditions that put the patient at risk
• Social History: Age appropriate review of past and current activities Smoking status, ETOH use, sexual activity, martial status, ect
• Don’t use “non-contributory”
• Instead use “Reviewed and no changes” or update as appropriate
Putting it all Together (S) • All three areas of history must line up with a level of service, or default to the lowest of the three
Components #1 and #2 History and Exam
Physical Examination (O)
• Problem focused • Limited exam of the affected body area or organ system
• Expanded problem focused • Limited exam of the affected body area or organ system and other
symptomatic or related organ system(s)
• Detailed • Extended exam of the affected body area(s) and other symptomatic or
related organ system(s)
• Comprehensive • General multisystem exam or a complete exam of a single organ system
Use the 1995 or 1997 E/M Guidelines
• Rule of thumb always perform a problem focused exam or expanded problem focused exam
Level of exam Perform and Document
Problem focused One to five elements identified by a bullet
Expanded problem focus
At least six elements identified by bullet
Detailed At least two elements identified by a bullet from each six areas/systems OR At least twelve elements identified by a bullet in two or more areas/systems
Comprehensive Perform all elements by a bullet in at least nine organ systems or body areas and documents at least two elements identified by a bullet from each of nine areas/systems
System/Body Area Elements of Exam
Constitutional • Measurement of 3 out of 7 of the following: 1) Standing BP; 2) Supine BP; 3) Pulse rate and regularity;4) respiration; 5) Temperature; 6) height; 7) Weight
• General appearance of patient
Eyes • Inspection of conjunctivae and lids • Examination of pupils and irises • Ophthalmoscopic examination of optic discs and posterior
segments
Ear, Nose, Mouth, Throat
• External inspection of ears and nose • Otoscopic examination of auditory canals and tympanic
membranes • Assessment of hearing • Inspection of lips, teeth, gums • Inspection of nasal mucosa, septum, turbinate's • Examination of oropharynx: oral mucosa, Salivary glands,
hard and soft palate, tongue, tonsils, pharynx
Obtain for all patients
System/Body Area Elements of Exam
Neck • Examination of neck (symmetry, masses, appearance) • Examination of thyroid (enlargement, tenderness, mass)
Respiratory • Assessment of respiratory effort (use of accessory muscles) • Percussion of chest (dullness, flatness, hyperresonance) • Palpation of chest (tactile fremitus) • Auscultation of lungs (breath sounds, rubs)
Cardiovascular • Palpation of heart (location, size, thrills) • Auscultation of heart (murmurs, abnormal sounds) • Carotid arteries (pulse, amplitude, bruits) • Abdominal aorta (size, bruits) • Femoral arteries (pulse amplitude, bruits) • Pedal Pulses (pulse amplitude) • Extremities for edema and varicosities
Chest • Inspection of breast (symmetry, nipple discharge) • Palpation of breast and axillae (masses, lumps, tenderness)
System/Body Area Elements of Exam
Gastrointestinal • Examination of abdomen (masses or tenderness) • Examination of lever and spleen • Examination for presence or absence of hernia • Examination of anus (hemorrhoids, rectal masses) • Obtain stool sample for occult blood test
Genitourinary • Examination of scrotal contents • Examination of penis • Digital rectal examination of prostate gland • Pelvic examination • Examination of urethra • Examination of bladder • Cervix • Uterus • Adnexa/parametria
Lymphatic Palpation of lymph nodes in two or more areas: Neck; Axillae; Groin; other
System/Body Area Elements of Exam
Musculoskeletal • Examination of gait and station • Inspection of digits and nails (clubbing, cyanosis,
inflammatory conditions, petechiae, infections) • Examination of joints, bones, and muscles of one or more of
the following: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; 6) left lower extremity
• Inspection and assessment: misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, range of motion, pain, crepitation, or contracture, stability, dislocation, contracture, muscle strength, muscle tone, atrophy, or abnormal movements
Skin • Inspection of skin and subcutaneous tissue (rash, lesion, ulcers)
• Palpation of skin and subcutaneous tissue
System/Body Area Elements of Exam
Neurologic • Test cranial nerves with notation of any deficits • Examination of deep tendon reflexes with notation of
pathological reflexes (Babinski) • Examination of sensation (tough, pin, vibration,
proprioception)
Psychiatric • Description of patient’s judgement and insight • Brief assessment of mental status including: 1) Orientation to
time, place, and person. 2) Recent and remote memory. 3) Mood and affect (depression, anxiety, agitation)
• Know your boundaries and when to refer out to a diagnostic provider for a more in-depth physical assessment.
• Basic vital should be completed at all patient visits regardless if billing based on time or medical decision making
Components #1 and #2 History and Exam
Complexity of Medical Decision Making (AP)
Number of Diagnosis or Treatment Options
Amount and/or complexity of data reviewed
Risk of complications and/or M/M
Type of Decision Making
Minimal Minimal or none Minimal Straightforward
Limited Limited Low Low complexity
Multiple Moderate Moderate Moderate complexity
Extensive Extensive High High complexity
• Must meet or exceed 2 of the 3 elements to qualify for the type of decision making
• Appropriate to use time of visit a predictor of complexity
• Multiple diagnosis (DM+HTN+DLD) + insulin should be moderate to high most of the time
• Low complexity (HTN, anticoagulation, Contraception) typically are straight forward
therapeutic decisions by themselves
Scoring Medical Decision Making (Marshfield Clinic Scoring)
Problem Points Data Points Risk Overall MDM
1 1 Minimal Straightforward Complexity
2 2 Low Low complexity
3 3 Moderate Moderate Complexity
4 4 High High Complexity
• Only 2 out of 3 elements required • Rare that review Data Points would meet high complexity when seeing established
patients • Patients is quite ill or requiring immediate emergency or specialty services
• Multiple uncontrolled condition • Severe exacerbation of a chronic problem • Acute illness that threatens life or bodily function
Problem Points
Problems Points Scoring Example
Self-limited or minor (Maximum of 2 points) 1
Established problem, stable, or improving 1 1 + 1=2
Established problem, worsening 2 2
New problem, with no additional work-up planned (Maximum of 1)
3
New problem, with additional work-up planned 4
Total 4=High complexity
New problem = New to the provider Not to be confused with definition of a new patient
Data Points Data Reviewed Points Example
Review or order clinical lab tests 1 1
Review or order radiology test 1
Review or order medicine test (PFTs, EKG, ect) 1
Discuss test with physician 1
Independent review of image, tracing, or specimen
2
Decision to obtain old records 1
Review and summation of old records 2
Total 1=Straightforward complexity
• 1 point given for reviewing and ordering updated HbA1c, CMP, Lipids
Risk Categories (Highly Subjective) Risk level Presenting Problem Diagnostic
procedure Management Options
Minimal Risk • Self limiting or minor problem (Cold, insect bites, Tinea Corporis)
• Standard clinical and medicine labs
• Rest, gargles, fluid, bandages
Low risk • 2+ Self limiting or minor problems
• 1 stable chronic illness • Acute uncomplicated
injury or illness (cystitis, allergic rhinitis)
• Physiologic test not under stress
• Non-Cardiovascular imaging studies
• Superficial needle biopsy
• ABG • Skin biopsies
• OTC drugs • Miner surgery • Physical Therapy • Occupational
Therapy • IV fluids no
additives
• Any of the elements in Any of the three categories listed
Risk Categories (Highly Subjective) Risk level Presenting Problem Diagnostic
procedure Management Options
Moderate Risk
• Two stable chronic dx • One chronic illness with
mild exacerbation/progression
• Acute complicated injury (fall w/ LOC)
• Physiologic test under stress
• Diagnostic endoscopies
• CV Imaging • Obtaining fluid
from body cavity
• Prescription drugs
• IV fluids w/ additives
• Nuclear medicine • Elective or minor
surgery
High Risk • 1+ chronic illness with moderate exacerbation/progression
• Acute or chronic illness that imposes threat to life or bodily function
• An abrupt change in status
• Invasive procedures
• Cardiac EP studies • Endoscopies
• Drug therapy requiring intensive monitoring
• Escalate/de-escalate based on poor prognosis
• Any of the elements in any of the three categories listed
Keep Medical Necessity Simple • Although a comprehensive service may be your personal art or style of practice it may
not be considered necessary and billable by a majority of peers
• It is the necessity of the work NOT the volume of work that should be coded and billed
• Even when billing based on time. The 50% of the visit that was focused on counseling
and coordinating care must be medically necessary for the disease state in
question/referral
Keep Medical Necessity Simple
Self Limiting Low Complexity
High Acuity Stable or Progressing
Moderate to High Complexity
Critically ill Prognosis poor
Highest Complexity
Keep Medical Necessity Simple
3 to 6 months follow-up Weeks to months Days to weekly
Using duration of follow up as guide can be helpful
Annually Non-problem
Oriented
Components #1 and #2 History and Exam
• Inclusion of time as an explicit factor since 1992 • Used to assist in selecting the most appropriate level of service
(LOS) for E/M CPT codes
• Used to determine LOS when counseling and/or coordinating care has dominated the visit
• CPT 2021 definitions of time:
• Time can be used whether or not counseling and/or coordination of care dominates the service
• Can used as proxy for determining the LOS of visit
• Time spent must be medically necessary and supported
similarly to determining the LOS for MDM
CPT Updates Definition of Time
• In 2021 time includes the following activities:
• Preparing to see patient (eg, review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals
• Documenting clinical information in the electronic health care record
• Independently interpreting results (not separately reported) and communicating results to patient
• Care coordination
CPT New Definition of Time
Time Based Billing
• When counseling and coordination of care predominate the visit (> 50%), then time is used to determine level of E/M service.
• Electing to use time to report the level of service the medical record should document.
• Length of face to face time should be documented
• Medical record should describe the counseling and activities done to coordinate care
Example of 99211 Visit LOS
• Established Patient 99211 Office visit for an established patient who is performing glucose monitoring and wants to check accuracy of machine with lab blood glucose by technician who checks accuracy and function of patient machine.
Office visit for a 73-year-old female, established patient with pernicious anemia for weekly B12 injection.
Example of 99212 Visit LOS
• Office visit for an established patient with hypertension who is being followed up for medication management and monitoring
• Office visit for Anticoagulation management and or warfarin adjustments
Example of 99213 Visit LOS
• Office visit for a 45 year-old asthmatic patient following up disease medication management who needs a renewal on their rescue inhaler. Patient was wheezing on exam and the dose of their ICS was increased.
• Office visit with an established, controlled diabetic who HbA1c is worsening while on maximally dosed oral diabetic medications. The patient is being reevaluated for therapy intensification, re-screened for hypertension, and dyslipidemia.
Example of 99214 Visit LOS
• Office visit for a 65 year old female, established patient, for review and follow-up of non-insulin dependent uncontrolled diabetes, obesity, hypertension, and heart failure. Complains of vision difficulties and admits dietary noncompliance. Patient was counseled and diabetic medication were adjusted and optimized.
• Office visit for an asthmatic patient who has missed multiple days of work due to asthma exacerbations. Patient noted having increased nocturnal awakening due to seasonal allergies. Upon exam findings suggesting acute maxillary sinusitis was noted and supervising physician notified (also could be assisted with confirmation). Asthma medication regimen was intensified (STEP UP), and montelukast was prescribed.
Level 5 Office Visit (99215)
• The 99215 represents the highest level of care for established patients being seen in the office.
• 99215 level of care was selected in about 9% of established office patients in 2014.
• Problems are of moderate to high severity • Documentation requires two out of three of the following
1) Comprehensive History
2) Comprehensive Exam
3) High Complexity Medical Decision-Making
• Or 40 minutes spent face-to-face if coding based on time • Nature of counseling and coordination of care must be clearly documented and be
medically necessary
Example 99215
Patient presents for follow-up of CHF. History of significant ischemic cardiomyopathy with an ejection fraction of 30%. Hypertension well controlled on current medications, but patient noted worsening lower extremity edema for the last 2 weeks.
Patient complains of severe SOB over the past 3 days. CAD stable with no chest pains. Patient is compliant with medication but has not been watching his salt intake carefully. ROS, PFSH reviewed and update. Blood pressure medication and diuretic medications were increased. Potassium supplement increase. Diet and lifestyle discussed. Follow up in 3 days for monitoring.
Example of 99215 Cont.
Patient presents for follow-up for uncontrolled diabetes, hypertension, and dyslipidemia. Patient has a history significant for CAD, and ischemic heart disease. Patient angina has been stable for over 3 years. Complains of feeling like an elephant was sitting on her chest last night. Patient HbA1c is 12%. BP: 175/102. Physical assessment revealed +4 AFIB, +3 Pitted Edema Bilaterally, and in clinic EKG was order and physician assisted with interpretation. Patient was referred to Cardiology and Sent to ER for further work-up.
Break
Show Me (E&M) Coding
Case #1 Coding
Patent HG: Evaluation and Management of Hypertension
• Chronic Disease Management Encounter
New or Established?
Received any Professional Service from the physician or other QHP in group of same
specialty within the last three years?
Yes No
New PatientExact Same Specialty?
Yes No
New patientExact Same Subspecialty?
Yes No
Established New Patient
Setting of Service: - 9920x or 9921x?
Scoring Key Components: History
HPI - (History)
HPI - (History)
ROS - (History)
PFSH - (History)
Final Score (History)
Scoring Key Components: Exam
Physical Exam (Examination)
Soring Key Components: Medical Decision Making
A. Number of Diagnoses or Treatment Options (MDM)
1 3 3
B. Data Reviewed (MDM)
1
C. Risk (MDM)
Final MDM Score…
Putting it all together
99214
But Wait! What About Medical Necessity?
Medical Necessity Met
Selecting LOS in EMR
Selecting LOS in EMR
CPT Code Association to Primary Diagnosis Code (ICD 10 Code)
Notes on ICD-10 Coding
• International Classification of Disease • Submitting an ICD-10 code on a claim is NOT Diagnosing
• Identifies the reason(s) for the service provided and supports medical necessity
• Codes may be taken from final assessment or chief complaint
• May include: • Disease or condition codes (A00-Q99 Codes)
• Finding or symptom codes (R00-R99 Codes)
• Injury, poisoning or external causes of morbidity (S00-Y99 Codes)
• Factors that influence health status and contact with health services (Z00-Z99 Codes)
ICD-10 Code Selection
• Know your scope of practice and privileging • Has a patient been diagnosed by a provider? • Patient provided self diagnosis? • Can you confer diagnosis? • Identify drug related problems? • Assess status of disease state?
• What Codes to Include • Diagnosis being addressed (to highest level of specificity)
• Ex: E11.21: T2 Diabetes w/ diabetic nephropathy vs E11 Diabetes Mellitus T2
• If diagnosis unclear or not established, the finding or symptom codes • Ex: R68.89 Flu-like Sx vs J10.19 Influenza due to Influenza A virus • DO NOT include rule out or probable diagnoses in outpatient settings
• If preventative, the reason for the encounter • Ex: Z71.89 Encounter for medication review and counseling
• Secondary conditions that impact treatment of presenting problem
Code on your own Code Cas #2: NL
1st: Use Our Note
2nd: Use Your Note
Coding Debrief
What did you get?
New or Established
9920?
Received any Professional Service from the physician or other QHP in group of same
specialty within the last three years?
Yes No
New PatientExact Same Specialty?
Yes No
New patientExact Same Subspecialty?
Yes No
Established New Patient
HPI - (History)
ROS - (History)
PFSH - (History)
Final Score… (History)
• Detailed History
Physical Exam (Examination)
A. Number of Diagnoses or Treatment Options (MDM)
1 3 3
B. Data Reviewed (MDM)
1
C. Risk (MDM)
Final MDM Score…
Putting it all together: 9920?
3/3 Key Components Required for New Patients
99201
How did your documentation do?
Break
Documentation With Intent to Bill
Documentation can make or break a practice
• Poor documentation can result in: • Leaving ‘money on the table’
• Overcoding
• Undercoding
• Fraud, Waste, Abuse
• Malpractice Risk
• Poor provider performance
• Errors in care transitions
• Patient harm/negative outcomes
Case #1: Note 2
Case #1 – Alternate HPI
Case #1 – Alternate HPI
Final Score (History)
Revised E&M Coding to Match Documentation
Old Documentation New Documentation
99213 99214
Business Case
99213
• 20 visits per day
• Medicare Rate for 99213 = $75.32
• Assume 40 working weeks per year x 5 Days per week = 4000 v/y
• 4000 x $75.32 = $301,280
99214
• 20 visits per day
• Medicare Rate for 99214 = $110.28
• Assume 40 working weeks per year x 5 Days per week = 4000 v/y
• 4000 x $110.28 = $441,120
Case #1: Note 3
99213!
Why 99213?
Why 99213?
3
Case #1: Note 4
99212
Why 99212?
1
Business Case
99212
• 20 Visits per day
• Medicare Rate for 99212 = $45.77
• Assume 40 working weeks per year x 5 Days per week = 4000 v/y
• 4000 x $45.77 = $183,080
99214
• 20 visits per day
• Medicare Rate for 99214 = $110.28
• Assume 40 working weeks per year x 5 Days per week = 4000 v/y
• 4000 x $110.28 = $441,120
Case #1: Note 5
99213!
Time Based Coding and Documentation
Case #1: Note 6
Not Billable! CC but no History or Exam
Only 1/3 Key Elements Documented
Overcoding
When the code billed is not supported by medical necessity: CPT Billed: 99215
• Medical Necessity of Presenting Problem:
• Moderate Severity
• 99213-4
Overcoding Continued
When face to face time is rounded up: CPT Billed: 99214
• Documentation of Face to Face time is 23 minutes
• Time for CPT codes are a range and do not permit rounding
• 99213: 15 – 24 Minutes
• 99214: 25 – 39 Minutes
Overcoding Continued
When the documentation does not meet the key elements of the code submitted but work does Ex: Billed 99214
• Note #4 • Documentation Supports 99212
• Work performed was 99214
Overcoding Continued
When the documentation does meet the key elements of the code submitted and incudes work not performed: CPT Billed: 99214
• Documented Comprehensive Exam
• Documented full ROS
• Whether intentional (to justify higher code or to provide extra reinforcement of code billed) or unintentional (EMR, late documentation) - FRAUD
Overcoding Continued
When the documentation does not meet the key elements of the code submitted and work does not: CPT Documented: 99215
• Work performed best described with 99214
• Documentation captured describes 99212
• Whether unintentional selection of 99215 or intentional - FRAUD
Undercoding
Under-documenting work provided: CPT Billed: 99212
• Note #4 – Documentation meets 99212
• Work performed best described as 99214
• Medical Necessity: Moderate Risk
• Could be intentional or unintentional*
Undercoding Continued
Coding below the work provided and the documentation provided CPT Billed: 99212
• Note #3: 99213 per Documentation
• Intentional or unintentional – still undercoding
• Provider billed 99212 to keep patient’s OV Copay low
Undercoding Continued
Provider coding 99211 when > straightforward MDM has occurred
Undercoding Continued
Using a ‘lower’ code to describe a ‘higher’ service: CPT Billed: 99606
• MTM CPT codes describe face to face interactions with pharmacist; review of medication history and use to identify medication or treatment related problems, recommendations for intervention.
• Focus is medication use, not disease state or medical condition problem.
Finding Balance with Documentation
• Let Medical Necessity Drive Documentation • Ideal when you start coding, will become second nature with time
• Features of ideal ‘real world’ documentation: • Maximizes reimbursement of the clinical encounter
• Provides a clear record of the care provided including decision making and plan
• Includes pertinent clinical information
• Is usable by all care team members and easily understood
• Minimizes liability
• Somewhere between billing minimum and didactic SOAP notes
Workflow Shortcuts
Electronic Medical Records
• Note Templates
• Smart Lists and Smart Links
• Smart Phrases
• Smart Blocks
• Preference Lists
Note Templates Note templates are Smart Phrases that are placed into a Quick Button to be used as the backbone of an encounter’s documentation.
The Smart Phrase may contain Smart Text that will pull in the last values in a lab or flowsheet (ex: BMI) or a Smart Block or Smart List that allows the user to select desired information at the point of service
Phone Note Template
Includes the ROS Smart Block and Smart Phrase to medication list.
Collaborative Drug Therapy Management Note Template
ROS Smart Block
Physical Exam Smart Block
Smart Phrases: Create Your Own or Share
Smart List vs Smart Links
PFSH Smart List (F/U Visit) PFSH Smart Link (New Patient Visit)
Personal Style and Preference
Template linked to CC vs Visit Type Old School (.SOAP Smart Phrase)
Utilize Preference Lists
Paper Chart Templates
Silver Lining
Where We Went
• 2016: Formal Establishment of Pharmacy Department at NHC • 2 Full Time Clinical Pharmacists • (1.5 Clinical FTE)
• 2017: Addition of 1 Full Time Pharmacy Technician
• 2018-9: Expansion to 3 Full Time Clinical Pharmacists • (2.4 Clinical FTE)
• 2020: Expansion to 5 Full Time Clinical Pharmacists 2 Technicians • (4.2 Clinical FTE)
Core Primary Care Teams
Core Care Team V1 Core Care Team V2
Care Team Model Team Members FTE
CCT V1 PCP Team Lead 1
PCP 1
PharmD 0.5
BH 0.5
RN 1
RN Case Manager 0.5
MA 2.5
Team Total
Care Team Model Team Members FTE
CCT V2 PCP Team Lead 1
PCP 2
PharmD 0.75
BH 0.75
RN 1-1.5
RN Case Manager 1-1.5
MA 4
Team Total
Clinical Pharmacy Services Provided
• Comprehensive Medication Reviews • Annual Reviews
• F/U Review and/or Interventions
• Targeted Medication Reviews
• Post Diagnostic Disease Management • Collaborative Drug Therapy Management
• Independent Authority
• Pharmacotherapy Consultation
• Preventative Services
NHC’s Payer Mix
Payer Class Percent of Total
Medicaid (CCO and FFS) 62%
Commercial 10%
Medicare (B or Managed Medicare)
6%
Self Pay 22%
100%
Pharmacist Billing of Medical Claims
Credentialed Medical Providers
• State Medicaid (FFS)
• 3 CCO Organizations
• 1 Managed Medicare Plan • MTM Services
• 5 Commercial Payors • MTM Services*
• E&M Services
Credentialing Not Eligible or Not Needed
• Medicare B • Incident-to
• Managed Medicare* • Incident-to
• Self Pay
NHC Pharmacist Visits
Clinical Pharmacist Specialist Schedule
• 8 hour work day split into 2 4 hour patient care sessions
• 9 sessions per week (0.9 FTE clinical care)
• 7 patient visits per session of 30 minutes
• 42 budgeted clinical work weeks per year
• 80% historical patient show rate
Total Encounters
• 2646 patient visits/year max
• Estimate 2116 visits completed if fully booked
• 2019 Witnessed Average/FTE = 2130 completed and billed encounters
NHC Claims Breakdown
Simple Revenue Projection in FFS Model
• Anticipated Claims x Average Claim Revenue
• Average claim Revenue $97.85 (for this example will assume E&M only)
• 2116 – 2646 Visits per year
• 1.0 CPS FFS Claim Revenue Estimate: $207,051 - $258,911
Real Life Payment Model
Payer FFS Wrap Capitation PFP Risk Sharing
Payer 1 No No Yes No No
Payer 2 Yes No Yes Yes Upside Only
Payer 3 Yes Yes N/A N/A N/A
Payer 4 Yes Yes N/A N/A N/A
Payer 5 Yes No No No Upside Only
Payer 6 Yes No No No No
Payer 7 Yes Yes Some Some No
Payer 8 N/A N/A N/A N/A N/A
Cash Yes N/A N/A N/A N/A
FINANCIALLY SUPPORTING AN ENHANCED CARE TEAM IN YOUR CLINIC
NATIONALLY, THINGS ARE CHANGING
Goals of the U.S.
Department of Health and
Human Services (HHS):19
• 30% of U.S. health care
payments in APMs or
population based
payments by year 2016,
and
• 50% by year 2018
Ten Models of Payment
Model Notes
FFS CPT code expansion
(fee for services)
Payment for non-traditionally reimbursed codes
FFS payment
enhancement
Increased FFS rate level based on quality
outcomes or tiers of clinic systems/providers
FFS + lump sum payments
(most common)
Periodic lump sums are paid for wrap around
services (NCQA PCMH Cert.)
FFS + PMPM
(per-member-per-month)
Engagement driven and often include pharmacy
services
FFS + P4P
(pay for performance)
Based on predetermined outcome or process
measures (HEDIS, STARS)
FFS with risk or shared
saving (PMPY)
Informed by ROI analysis and can include medical
and pharmacy savings
Ten Models of Payment
Model Notes
FFS + PMPM + P4P Monthly care coordination and retrospective
outcome based payments (6-12 months)
FFS + Lump Sum + P4P No requirements for lump sum with quality metrics
for P4P
FFS + Lump Sum + P4P +
PMPY
No requirements for lump sum with quality metrics
for shared savings that are risk adjusted for case
mix
Comprehensive Risk adjusted PMPM that covers all services and
payments
Ten Methods of Payment20
Fee for Service Capitation/Care
Management
Quality Payments
Total Cost of Care/Risk
Contracting
Methods of Payment
• Traditional source of income based on service performed
• Negotiated with individual payers
• The ten payment models purposed • FFS plays a role in 8/10 of the models
• CPT and FFS is not going away any time soon • Provide a baseline minimum payment
• Used for data acquisition purposes • Outcomes
• Gaps in care
• Risk adjustment
• Engagement visit
Fee for Service
Methods of Payment
• Per member per month (PMPM) payment for attributed members • Can be for specific services (e.g.. Care Management)
• Global payment for primary care
Benefits
• Supports non-encounterable interaction
• Allows flexibility in the model (depending on criteria in contract)
• Decreases administrative hassle and allows ability to align
• Supports team based care model
Drawbacks • Relies on team based care model
• Need payer penetration to make viable
Capitation/Care Management
Methods of Payment
• Bonuses for meeting incentive metrics: • Incentive Measures
• Medicare Stars Measures
• HEDIS Measures
• NCQA PCMH
Quality Payment
Benefits • Allows additional revenue for demonstrating process and outcome
metrics
• With focus and priority, are achievable
Drawbacks • Less predictable
• Measures and payments vary across payers
Methods of Payment
• Shares financial risk of care delivery
• Calculates projected cost for a population
• Negotiates upside and downside shared risk for achieving the target budget
Total Cost of Care/Risk
Contracting
Benefits • Allows maximal flexibility as long as outcomes are achieved
• Supports development of deeper population management capability
Drawbacks • Requires infrastructure and financial support to taking risk
• Need relationship with hospital and specialty partners to maximize effectiveness
APM Example
PCMH Potential Revenue Streams
Total Qualifying Encounters 15,000
Total FFS Revenue $1,500,000
PMPM Case Rate $250/month
Penetration 2016 30%
Adjusted PMPM Revenue $375,000
P4P Metrics Met 6 of 15
Weighted P4P Revenue $875,000/$2,200,000
County Level Capitation Rate (wrap rate) $284
Eligible PPS Encounters 8,000
Wrap Revenue $1,472,000
Total Revenue (FFS+PMPM+P4P+Wrap) $4,222,000
CareOregon’s Clinical Pharmacy Network
2019
2 20
42
67 89
108
0
20
40
60
80
100
120
2014 2015 2016 2017 2018 2019
PH
AR
MA
CIS
TS
YEAR
CareOregon Credentialed Pharmacists 2014-2019
Total Count
Year Over Medical Claims Submissions
43
706
6006 6122
7705
5975
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2014 2015 2016 2017 2018 Jan - Oct 2019
MED
ICA
L C
LAIM
S
YEAR
Distribution CPT Categories 2014-2016
4 170 178
6309
5 89 0
1000
2000
3000
4000
5000
6000
7000
Drugs Evaluation & Management
Labs/Screenings MTM Preventative Medicine
Vaccinations
MED
ICA
L C
LAIM
S
CPT CODE GROUPINGS
Distribution CPT Categories 2017-2018
156
2549
1015
9659
66 382
0
2000
4000
6000
8000
10000
12000
Drugs Evaluation & Management
Labs/Screenings MTM Preventative Medicine
Vaccinations
MED
ICA
L C
LAIM
S
CPT CODE GROUPINGS
Distribution CPT Categories 2019
71
2635
825
2184
40 220
0
500
1000
1500
2000
2500
3000
Drugs Evaluation & Management
Labs/Screenings MTM Preventative Medicine
Vaccinations
MED
ICA
L C
LAIM
S
CPT CODE GROUPINGS
Sustainability is Possible
Questions?