Billing for Pharmacist Collaborative Patient Care Services

Transcription

1 3/9/15 SCSHP 15 Annual Meeting Disclosure Billing for Pharmacist Collaborative Patient Care Services Bob Davis, PharmD, FAPhA Professor, Kennedy Pharmacy Innovation Center, University of South Carolina Clinical Professor, Clinical Pharmacy and Outcomes Sciences, SCCP Bob Davis does not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation. Kennedy Pharmacy Innovation Center Foundation established in 1 at USC through significant alumni gift Fosters creativity and innovation by connecting passionate, forward thinking, entrepreneurial pharmacy students, educators, and practitioners Develops and supports entrepreneurial training and programs, and the exploration of new sustainable business models Transforms pharmacy practice into viable, effective patient centered care model by providing tools, resources, and relationships Learning Objectives Describe the clinical and financial outcomes of the Comprehensive Medication Management Collaborative. Describe the emerging outpatient collaborative care management programs that can provide revenue for pharmacist patient care. Explain regulatory requirements to bill for pharmacist services using Evaluation and Management codes. Explain the Evaluation and Management Key Components and Contributory Factors that must be satisfied to bill for pharmacist care services. Select an appropriate level of Evaluation and Management Service for pharmacist care services. The Need for Pharmacists Services Drug related morbidity cost the US over $B annually Patients with chronic conditions take an average of 5 prescription medications concurrently Only 33% 5% of patients with chronic conditions adhere to the medication treatment plan Most common reasons apatient on medication visits their physician: Dosage titration Add new drug Medication outcomes monitoring Adverse event 3% of adverse events leading to hospital admissions are related to medication Payment Landscape for Pharmacists In response to a January, 1 inquiry from the AAFP, Marilyn Tavenner, CMS Administrator, responded on March 5, 1 stating: In your letter, you ask that we confirm your impression that if all the requirements of the "incident to" statute and regulations are met, a physician may bill for services provided by a pharmacist as "incident to" services. We agree. On July 3, 1, Marc Hartstein, Director, Hospital and Ambulatory Policy Group, CMS wrote a reconfirming letter to UNC Health Care: a physician may bill for the services of a pharmacist under their supervision with which they have a relationship that meets the requirements of CFR 1.6,, if the services being provided are consistent with state law and meet all other requirements of the incident to rules. 1

2 3/9/15 Regulatory Billing Requirements Collaborative practice Billing through recognized provider Employment relationship Pharmacist's Scope of Practice includes authority to: Take patient history Perform limited examination Make medical decisions Provider Payment Models Visit based fee for service (FFS) Monthly care coordination fee Value based fees (FFV) Performance and Efficiency Bundled Groupings Performance based incentives Quality Bonus (PP) Shared Savings Facility Fee Integration Fee Emerging Pharmacist Care Management Annual Wellness Visit (AWV) Medication risk factors, routine measurements and vital signs, immunizations, medication review, and cognitive, mobility, and depression screenings. (FFS) Transitional Care Management (TCM) High risk patient identification, medication list verification, discharge plan reinforcement, medication reconciliation and management. (FFS) Chronic Care Management (CCM) Patient care plan, medication risk factors, immunizations, medication review, and cognitive, mobility, and depression screenings, non face to face care coordination and medication management. (FFS) Emerging Outpatient Care Management Care Management/Coordination Patient care plan, medication risk factors, immunizations, medication review and reconciliation, and cognitive, mobility, and depression screenings, non face to face care coordination (Bundle) Population Health Management High risk patient identification, medication reconciliation, and nonface to face medication management, treatment standardization, evaluate outcomes (PP) Incident to Collaborative, face to face comprehensive medication management, self care management counseling, device training, evaluate outcomes (FFS) E & M Key Components (Pharmacy) History Chief compliant, history of present problem, review of pertinent systems, related family and social history Examination Limited examination of affected area or organ Medical Decision Making Selecting a management option Must satisfy of 3 Key Components Time considered when 5% of visit is for patient counseling and education Evaluation and Management Codes CPT Code Description Share Value G Initial Preventative Physical Exam (IPPE) 1% % G38 Initial AWV Review (AWV) 1% 35% G39 Yearly AWV Review (AWV) 1% 35% 9965 CMM Initial Patient Visit 1% 9966 CMM Established Patient Visit 1% 9967 CMM Extended Visit 1% Model Impacted by Shared Visit Revenue Splits

3 3/9/15 Evaluation and Management Codes CPT Code Description Share Value 9911 Outpatient visit Incident to 1% 991 Outpatient visit Incident to 8% 9913 Outpatient visit Incident to 5% 991 Outpatient Visit Incident to % 5% 999 Chronic Care Management (CCM) 35% 75% 9995 Transitional Care Management (TCM) 1% 35% 9996 Transitional Care Management (TCM) 1% 35% Model Impacted by Shared Visit Revenue Splits Pilot Overview Scope: To develop and evaluate collaborative, sustainable business model(s) for pharmacist provided Comprehensive Medication Management (CCM) services within a PCMH. Focus: Patients with diabetes, lipid disorders, hypertension, congestive heart failure, obesity, and multiple/complex therapies. Agreements: Collaborative Practice Agreements, Scope of Practice, and Treatment Algorithms. Funding: BCBS SC MTM and KPIC pharmacist. Time: November 1, 13 October 31, 1. Outcomes: Revenue, Quality, Satisfaction, Cost Avoidance, and Productivity. Comprehensive Medication Management ensures that each patient's medications are individually assessed to determine Appropriateness for the patient Effectiveness for the medical condition Safe with other comorbidities and medications Through counseling and ongoing coaching builds medication self management competency Key Elements: Initially delivered directly (face to face) to patient Includes comprehensive assessment of the patient s medication related needs Includes individual care plan A collaborative care team includes pharmacist Collaborative Practice Agreements Document establishing the contractual delegation of patient care authority between providers Defines pharmacist as a mid level provider Creates environment for: Improved patient access and quality Comprehensive Medication Management Components include: Scope of Practice (delegation of authority) Job Description (qualifications) Medication Management Pathways (algorithms) Quality A1c Improvement Patients with A1c >1. Patients with A1c >7. Mean A1c Improvement Mean A1c Improvement % 11.% Quality LDL Improvement Patients with LDL C >13 Patients with LDL C >8 Mean LDL Improvement.5% Mean LDL Improvement 16.% % Patients Improved 77.% Patients Improved Patient retrospective chart reviews Evaluation period November 13 October 1 Minimum pharmacist visits and pre/post A1c 86.% Patients Improved 186 Patient retrospective chart reviews Evaluation period November 13 October 1 Minimum pharmacist visits and pre/post LDL C 79.1% Patients Improved 3

4 3/9/ Quality HBP Improvement Patients with Systolic >1 Patients with Diastolic >9 Mean SBP Improvement Mean DBP Improvement % 1.1% Satisfaction Provider.7 Willingness to Recommend/Refer Patient.9 Staff 5. 7.% Patients Improved 81.3% Patients Improved 31 Patient retrospective chart reviews Evaluation period November 13 October 1 Minimum pharmacist visits and pre/post BP 15% of patients volunteered they would change behavior based on pharmacist s coaching. Cost Avoidance Physician Productivity Month Encounters Interventions $ Avoidance Avoid/Encounter April 5 99 $139,6 $ May $18,379 $ June 99 $151,531 $ Typical Interventions Medication reconciliation Allergy identified, clarified or prevented Lab/test evaluation, patient consultation or recommendation Medication change of dose adjustment Patient counseling-self care: diet, exercise, checking blood sugars, OTC recommendation, smoking cessation Adverse effect identified/remedied Cost Avoidance from data of 3 independent studies by Suh, Classen and Bates and used by Pharmacy OneSource Quantifi software for reporting financial impact of pharmacist clinical interventions. Average intervention savings was $ Contributing Factors: Fee Increase November 13 More New Patient Visits More Complex Visits % Increase.6% % Total Referrals to PharmD 13 Q 1 Q Provider Visits/Day Visits/Day MDA $,71 $3,99 7.7%. 5. 6% MDB $3,1 $3,71 19.% % MDD $,6 $3, % % MDT $,58 $3, 16.% % MDV $,878 $3,177 1.%..7 7% AVERAGE $,781 $3,35.6% Return on Investment New Expenses $ 1, Value Annualized Revenue (FFS & PP) $ 98, Physician Productivity $, Cost Avoidance/Quality $1,756, Customer Satisfaction Priceless ROI 15:1 Resources Buck, Carol J. 1 ICD 9 CM, Professional Edition for Physicians, Vol 1 &, American Medical Association. 1 Current Procedural Terminology, Professional Edition, American Medical Association. Medical Benefit Policy Manual, access February 15, and Guidance/Guidance/Manuals/Downloads/bp1c15.pdf Classen, DC, Pestotnik, SL, Evans RS, Lloyd JF, Burke JF. Adverse drug events in hospitalized patients, JAMA, 1997; 77: Classen, DC, Pestotnik, Evans RS, Burke JF. Computerized surveillance of adverse drug events in hospitals patients, JAMA, 1991; 66: Bates DW, Spell N, Cullen DJ, et all. The cost of adverse drug events in hospitalized patients. JAMA 1997; 77: Suh DC, Woodall BS, Shin SK, Hermes de Santis ER. Clinical and economic impact of adverse drug reactions in hospitalized patients. AnnualsPharmacotherapy ; 3:

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