Overview of Current and Future Coding PSTAC May 18, 2010 Presentation Prepared by: Shelly Spiro 1
Role and Current Work of Each Standards Development Organizations (SDO) Overview HL7 X12 NCPDP Harmonization Proposed MTM Coding Objectives 2
Federal Advisory Committees Policy and Standards Committees http://healthit.hhs.gov/ Recent Regulations Meaningful Use (MU) Med Reconciliation (MR) Transition of Care (TOC) Standards and Certification erx for Controlled Substances Privacy and Security SDO Oversight 3
Source: HIT Standards Committee Implementation WG Start Kit Model 3-24-10 HIT Standards Committee Model 4
Meaningful Use MU of EHR Incentives for "eligible professionals (EP) Recognition of Pharmacists eprescribing EHR Work Group project Pharmacists/Pharmacy Provider EHR Functional Profile Exchange of clinical information (CCD & CCR messaging using CDA) Health Information Exchange (HIE) Personal Health Records (PHR) Health Level Seven (HL7) 5
NHIN Source: HIT Standards Committee Implementation WG Start Kit Model 3-24-10 6
Source: HIT Standards Committee NHIN Direct Model 4-28-10 What is the NHIN Direct Project? 7
Source: HIT Standards Committee NHIN Direct Model 4-28-10 Who are the Participants? 8
Source: HIT Standards Committee NHIN Direct Model 4-28-10 NHIN Direct is Open and Collaborative 9
Source: HIT Standards Committee NHIN Direct Model 4-28-10 HIT Standards Committee Model 10
837 Professional CICA Project Pharmacist Implementation Guide CPT and Quality codes Process s for Payer-Driven MTM Services Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) credentialing X12 11
E-Prescribing SCRIPT Standard - Extensible Markup Language (XML) Format Clinical Information Exchange (CHIX) TG RX-Norm, Codified SIG, epa, CS Work Group (WG) 10 MTM Communications Task Group Overview of gap analysis NCPDP 12
1. Payer identifies patient to pharmacist... 2 2. Pharmacist identifies patient to payer... 4 3. Prescriber identifies patient to payer/ Other health care professional identifies patient to payer... 6 4. Prescriber identifies patient to pharmacist/other health care professional identifies patient to pharmacist... 8 5. Patient self-identifies to pharmacist/ Patient self-identifies to payer... 9 6. LTC/nursing facility identifies patient to pharmacist... 11 7. Obtain information prior and during performing service... 13 8. Reporting Service (Service Documentation)... 17 9. Bill... 19 10. Follow-Up... 20 11. Remittance Advice... 21 12. Outcomes Aggregate Reporting... 22 13. Referral... 27 14. Pend... 28 15. MTM Fields... 31 15.1. Indication (Reason) for MTM Service... 33 15.2. Type of Service Required/Recommended... 36 15.3. MTM/Professional Service Performed/Provided by Pharmacist... 37 15.4. Results of Provider Actions/Interventions... 40 15.5. Complexity of Care... 41 16. Reference Information 43 TCM Provider-Payer Communication Use Case NCPDP WG10 MTM Communications TG 3-16-10 13
NCPDP WG10 -MTM TCM Sub-TG 11-25-08 Flow Chart of MTM Service Originating with a Provider 14
NCPDP WG10 -MTM TCM Sub-TG 11-25-08 Flow Chart of MTM Service Originating with a Payer 15
PHR communication with pharmacy Communication between LTC Pharmacy and the Facility Communication related to Hospice Documentation of the MTM Service (Actions, Reasons, Results) Reporting aggregate or detail results Identification of service by a payer to a pharmacy -DERF Gap Analysis NCPDP WG10 MTM Communications TG 3-16-10 16
TG agreed this is the first gap to tackle No standard transactions exists X-12 requested more information NCPDP Using SCRIPT XML DERF being submitted for May 2010 JTWG meeting DERF outcome and next steps Payer Requesting Service Gap 17
Work Group (WG) 10 MTM Communications Task Group TG agreed next to focus on Documentation of the MTM Service Coding Reasons, Actions and Results NCPDP 18
Physician/Payer referral unspecified Patient self-identification/self-referral Physician/Payer referral, Patient self-referral or pharmacist identification 1 Complications of care (new field) A Discontinuity of Care (i.e. transition of care) B Fragmentation of Care (i.e. care from multiple prescribers) C At least one chronic disease or health condition (need a way to communicate how many) D Taking multiple chronic medications (need a way to communicate how many) E Lab values outside of normal range that could be potentially improved by drug therapy F Cost of Care (i.e. formulary or financial concerns) G Health literacy concerns 2 Suspected or identified problems (medication-related problems) A Non-specified 0 non-specified B Indication 0 non-specified 1 need for therapy based on evidence-based guidelines and/or best practices 2 unnecessary treatment duplicate therapy 3 unnecessary treatment no medical indication C Effectiveness 0 non-specified 1 suboptimal drug selection 2 insufficient dose/duration 3 inadequate clinical response 4 non-compliance with evidence based treatment guidelines D Safety 0 non-specified 1 actual or potential adverse event 2 drug interaction 3 excessive/dose duration 15.1 Indication (Reason) for MTM Service NCPDP WG10 MTM Communications TG 3-16-10 19
Could be utilized to provide information on referral/identification of a patient in need of MTM service by physician, payer or pharmacist When referral by physician/payer - provides specificity of services that clearly define the scope of services to be provided to the patient Multiple services need to be available for each encounter 15.2 Type of Service Required/Recommended NCPDP WG10 MTM Communications TG 3-16-10 20
Transition of care consult (Comprehensive medication therapy review and personal medication record creation as per MTM Core Elements Version 20 or most current version) Comprehensive medication therapy review consult (as specified in the MTM Core Elements Version 2.0 or most current version) Targeted medication therapy review consult (initial) (as specified in the MTM Core Elements Version 2.0 or most current version) Targeted medication review (follow-up) (as specified in the MTM Core Elements Version 2.0 or most current version) Health literacy consult (should we include? One payer stated they have interest specifically in this as stand-alone service) Functional abilities consult Cost efficacy/formulary management consult Adherence Assessment consult Therapeutic drug monitoring/pharmacokinetic consult Disease Education (sub-categories of common disease states?) 1. Individual 2. Group 15.2 Type of Service Required/Recommended NCPDP WG10 MTM Communications TG 3-16-10 21
Existing MTMS Category 1 CPT s Need for MTM Core Elements service documentation & other MTM services based on the existing CPT codes: Existing CPT codes define and encompass a medication therapy review (comprehensive or targeted) & Intervention Additional mechanisms are needed to document services performed to collect data for future CPT code creation Certain MTM-related services are very narrowly focused and do not involve a medication therapy review (health literacy assessment, functional abilities assessment, adherence assessment, cost/formulary consult) 15.3 MTM/Professional Service Performed/Provided by Pharmacist NCPDP WG10 MTM Communications TG 3-16-10 22
Need for MTM Core Elements service documentation & other MTM services based on the existing CPT codes (cont.) The needs of all stakeholders for specific granularity of services performed Multiple codes may be necessary in a billing/documentation encounter Patient is assigned a case number/reference number The pharmacist sees the patient numerous times on a given day, each is an encounter Each encounter consists of one or more services performed 15.3 MTM/Professional Service Performed/Provided by Pharmacist NCPDP WG10 MTM Communications TG 3-16-10 23 23
99605 MTM CPT s New Patient - Medication therapy review performed (comprehensive or targeted) (as specified in the MTM Core Elements Version 2.0 or most current version) - Intervention (as specified in the MTM Core Elements Version 2.0 or most current version) 99606 MTM CPT s Existing Patient - Medication therapy review performed (comprehensive or targeted) (as specified in the MTM Core Elements Version 2.0 or most current version) - Intervention (as specified in the MTM Core Elements Version 2.0 or most current version) Personal Medication Record prepared and provided to patient (as specified in the MTM Core Elements Version 2.0 or most current version) Medication-related Action Plan prepared and provided to patient (as specified in the MTM Core Elements Version 2.0 or most current version) Referral (as specified in the MTM Core Elements Version 2.0 or most current version) 0 Non-specified or other 1 For evaluation and diagnosis 2 Disease management education 3 Monitoring for high risk medications Documentation (as specified in the MTM Core Elements Version 2.0 or most current version) 1 Patient specific record created (SOAP or equivalent, care plan, PMR, MAP, history, etc.) 2 External communication to patient s other health care providers (SOAP, care plan, PMR) Intervention (as specified in the MTM Core Elements Version 2.0 or most current version) 1 Non-specified 2 Recommendation/consultation with other health care provider 3 Patient education/training 4 Patient monitoring Alternative therapy identified & initiated via Prescriber Consult (cost/formulary) Education/training provided Pharmacokinetic consult performed Health literacy assessment conducted Functional abilities assessment conducted Adherence assessment conducted Disease specific education provided MRR conducted (as per? practice guideline for MRR to reference?) Patient contacted for recruitment into service 15.3 MTM/Professional Service Performed/Provided by Pharmacist NCPDP WG10 MTM Communications TG 3-16-10 24
Optional field not always reporting these for every documented encounter These would be used in a similar way that CPT II codes are utilized now in physician quality reporting initiatives Supplemental tracking codes Used for performance measurement to facilitate the collection of data about quality of care Not used for billing purposes 15.4 Results of Provider Actions/Interventions NCPDP WG10 MTM Communications TG 3-16-10 25
Patient Refusal of service Initiation of cost effective/formulary drug Prescriber refusal of recommendation Prescriber acceptance of recommendation Sub-code: Initiation of new drug therapy Sub-code: discontinuation of drug therapy Sub-code: Change of existing drug therapy Sub-code: Other? Patient refusal of recommendation Patient changed adherence behavior (use on follow-up only) 15.4 Results of Provider Actions/Interventions NCPDP WG10 MTM Communications TG 3-16-10 26
Capture important information about the patient (amount and complexity of MTM information considered by the pharmacist) Correlation between this field and the amount of time pharmacists spend with patients Need to include in model? Waiting for PSTAC MWG for further work on classification system 15.5 Complexity of Care Proposed -MTM Medication Regimen Complexity (MRC) NCPDP WG10 MTM Communications TG 3-16-10 27
Work Group (WG) 10 MTM Communications Task Group National Library of Medicine (NML) offer Documentation Exchange (SDO modeling and harmonization) Difference between coding and billing NCPDP 28 28
SNOMED CT (Systematized Nomenclature of Medicine--Clinical Terms) International Health Terminology Standards Development Organization (IHTSDO)out of Denmark SNOMED coding content structured as IHTSDL (Jim Case is to SNOMED as John Kilbourne is to RXNORM) 10 member country US NML handles the franchise NLM SNOMED CT 29
To support the community of practice who are developing EHR systems Allow appropriate retention, processing and exchange of explicit clinical records Support patient-centric actions Fast transfer of records between different healthcare providers Referred to as 'semantic interoperability Provision of SNOMED CT 30
Website http://www.nlm.nih.gov/research/umls/snomed/snomed_ main.html SNOMED Core Content http://www.nlm.nih.gov/research/umls/snomed/core_subs et.html SNOMED CT User Guide http://www.ihtsdo.org/fileadmin/user_upload/docs_01/sn OMED_CT/About_SNOMED_CT/Use_of_SNOMED_CT/SNOM ED_CT_User_Guide_20090731.pdf Technical Specifications for creating a Ref Set http://www.ihtsdo.org/fileadmin/user_upload/docs_01/tec hnical_docs/reference_sets.pdf SNOMED CT References 31
Clinical finding Physical force Procedure Event Observable entity Content coverage is Divided into Hierarchies Environment or geographical location Body structure Social context Organism Situation with explicit context Substance Staging and scales Pharmaceutical/biologic product Linkage concept Specimen Qualifier value Special concept Record artifact Physical object Hierarchies 32
Betsy Humphrey (head of NLM) doesn t want organizations to set up another code system They want us to set up a value set using SNOMED and add our codes to SNOMED John Kilbourne (NLM) recommends that PSTAC does a gap analysis on Reasons/Actions/Results proposed codes to SNOMED Reasons (Type of Service and Indication) Actions (Documents the event including CPT codes used) Results John recommends changing Results to Outcomes Results are used more for treatment results (e.g. Labs) NLM Proposal 33
Create a Value Set - use a real use case Example MTM Create a statement and purpose SNOMED gap analysis PSTAC to create and maintain the Value Set Value Set would then be warehoused at the NML MTM CPT codes can be included in the Value Set PSTAC would set the version number and be the author PSTAC can own the codes as a SNOMED Extension Value Set 34
SNOMED CORE EXTENSION Definition of an Extension - SNOMED codes that don t have codes Some can live in the core or some are out E.g. Diabetes Education is in and targeted MTM is out SNOMED Extension Model 35
Vocabulary Task Force Addresses vocabulary subsets and value sets Facilitates and enables HER meaningful use Meets monthly Jamie Ferguson (Kaiser) chairs the Clinical Operations WG The Clinical Operations Workgroup Recommends EHR requirements to the HIT Standards Committee EHR certification criteria Standards Implementation certifications related to clinical operations HIT Standards Committee s Clinical Operations Workgroup 36
Jamie Ferguson, Co-Chair, Kaiser Permanente Christopher Chute, Mayo Clinic Martin Harris, Cleveland Members John Halamka, Co-Chair, Harvard Medical School Wes Rishel, Gartner Nancy Orvis, Department of Defense Keven Hutchinson, Prematics Elizabeth Johnson, Tenet Health John Klimek, NCPDP Karen Trudel, HHS/CMS Cris Ross, MinuteClinic Joyce Sensmeier, HITSP Don Bechtel, HITSP HIT Standards Committee s Clinical Operations WG Members 37
We are now well below the surface! Reproduction of this picture is not allowed with prior approval 38
PSTAC s involvement in SDO activity and harmonization efforts CCHIT and or other federally recognized Pharmacists/Pharmacy Provider EHR-S certification process (Environmental Scan) MTM Reason-Actions-Results codes NLM involvement PSTAC business model Quality measures Patient-centric medical home technology model Discussion Points 39
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