Billing Boot Camp I: Basic Training -...

© 2016 by the American Pharmacists Association. All rights reserved.

Billing Boot Camp I

Mary Ann Kliethermes, BS Pharm, PharmD

Sandra Leal, PharmD, MPH, FAPhA, CDE

Gloria Sachdev, BS Pharm, PharmD2

Billing Boot Camp I: Basic Training

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Disclosures• Mary Ann Kliethermes is co-owner of Clinical pharmacy

Systems Inc.

• [INSERT FACULTY NAME(S)] [INSERT THE FOLLOWING TEXT IF NO CONFLICTS EXIST: “declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.” OR LIST THE CONFLICTS ]

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

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• Target Audience: Pharmacists

• ACPE#: 0202-0000-16-012-L04-P

• Activity Type: Knowledge-based

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Learning Objectives

• Explain basic billing terminology.

• Discuss the types of billing opportunities for pharmacists’ services.

• Explain general requirements for billing patient care services in the health care system, including Medicare.

• Identify the key billing decision makers and their influence on pharmacists billing services.

• Describe medication therapy management and billing codes for incident to physician services and how these codes are used to bill for pharmacists’ patient care services.

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CPT Codes are:

A. Level 1 HCPC (Healthcare Common Procedure Coding System) codes

B. Codes that include the “incident to” Evaluation & Management codes which providers may use to support pharmacist services

C. Used by Medicare Part B for billing purposes

D. Adjusted by the Resource-based Relative Value Scale (RBRVS)

E. All of the above


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APC (Ambulatory Payment Classifications) Codes are used in which setting?

• Hospitals or health-systems for “facility fee” services in their ambulatory clinics

• Physician offices for diabetes education services

• Assisted living and group homes for clinical provider services

• For in-home services provided by Medicare Part B providers

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Which one of the following statements is NOT a CMS criteria for billing incident to physician in a hospital-based outpatient clinic?

A. Must have an order/referral

B. Must have Direct Physician Supervision

C. Must have a continued physician relationship

D. Must be considered a recognized provider

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Which of the following is a TRUE Statement?

A. MTM CPT codes can be billed under Medicare Part B

B. MTM CPT codes can be billed under Medicare Part D

C.MTM is required by Medicare to be provided by pharmacists

D.MTM is an “opt-in” requirement of Medicare prescription drug plans

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What are key opportunities for pharmacists to comment on impending Medicare rules?

A. There is never an opportunity for pharmacists to comment on rules.

B. During the Notice of Proposed Rulemaking

C. During the Interim Final Rule

D. After the Final Rule is implement

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“Je ne sais pa”Understanding

Billing Language


Vice-Chair, Professor

Chicago College of Pharmacy

Midwestern University

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Learning Objective

• Explain basic billing terminology

i.e. Words and acronyms you should know and have a basic understanding of what they mean


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Demystifying the language

Payer Site/type

Coding• Services• Disease

Forms Rules

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Whose language do we need to understand?

Federal Medicare

Part A

Part B

Part C

Part D

State

Medicaid

Insurance exchanges

Commercial or Private

Employer based

Group

Individual

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Commercial Health Insurance Language

Conventional indemnity plan • Allows the participant the choice of any provider without effect on

reimbursement. Reimburse as expenses are incurred.

PPO (Preferred provider organization)• Coverage is provided through a network of selected health care

providers. Enrollees may go outside network, but incur larger costs.

EPO (Exclusive provider organization)• A more restrictive type of preferred provider organization plan.

Employees must use providers from the specified network. There is no coverage for care received from a non-network provider except in an emergency situation.

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Group Model HMO

• Contracts with a single multi-specialty medical group, the group may only see HMO patients or it may also provide services to non-HMO patients.

Staff Model HMO

• Closed-panel, members receive services only from providers who are HMO employees.

Network Model HMO

• Contracts with multiple physician groups to provide services to members.

IPA (Individual Practice Association) HMO

• A group of independent providers who maintain their own offices and band together to contract their services HMOs.

HMO (Health maintenance organization)

• Assumes financial risks associated with providing medical services & for health care delivery usually in return for a fixed, prepaid fee. Reimbursement only to HMO providers.

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POS (Point-of-service) • A POS plan is an "HMO/PPO" hybrid• Resemble HMOs for in-network services. • Outside of the network are reimbursed like an indemnity plan

( reimbursement based on a fee schedule or usual, customary and reasonable charges).

PHO (Physician-hospital organization) • Alliances between providers & hospitals to help providers attain market

share, improve bargaining power & reduce administrative costs. • Sell their services to managed care organizations or directly to

employers.

Medigap Supplemental Plans• Pays the Medicare deductibles, copayments, and other expenses

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Payer Site/type

Coding• Services• Disease

Forms Rules


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CMS: Center for Medicare and Medicaid Services(HCFA – Health Care Financing Administration – old name)

Medicare Part A

• Universal benefit

• Covers • Hospitals,

Health Systems

• Long term care

• Hospice and Home Health

Medicare Part B

• Must Opt out• Must have

contributed to Social Security

• Covers outpatient services

Medicare Part C

• May opt in • Medicare

Advantage• Administered

by commercial payers

Medicare Part D

• May opt in• Administered

by commercial payers (PDPs)

Hospital PDPsCommercial

PayersProvider

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Medicare Part A Inpatient Services

Governed by IPPS (Inpatient Prospective Payment System)• MS-DRGs (Medical Severity Diagnosis Related

Groups)• Over 700 clinically cohesive groups that

demonstrate similar consumption of hospital resources and length of stay

• Example MS-DRG 007 – liver transplant• Revenue Codes (4 digits numeric)

• Example 0120 Room and Board/semi-private

www.cms.gov

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Medicare Part B

Governance documents• PFS (Physician fee schedule)• EHR Incentive Programs “Meaningful use”• PQRS (Physician Quality Reporting

System)• HOPPS (Hospital Outpatient Prospective

Payment System) for hospitals

www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-2016.pdf 22

Medicare Part B and Outpatient Hospital ServicesGoverned by

• HOPPS (Hospital Outpatient Prospective Payment System)

• APC or “Facility Fee” Code– Pays the hospital the costs of using the facility to provide services

to the beneficiary

– Where hospital employees may bill for services

https://www.gpo.gov/fdsys/pkg/FR-2015-11-13/pdf/2015-27943.pdf

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Medicare Part B Provider List

• Anesthesiology Assistants

• Audiologists

• Certified Nurse-Midwives

• Certified Registered Nurse Anesthetists

• Clinical Nurse Specialists

• Clinical Psychologists

• Clinical Social Workers

• Mass Immunization Roster Billers, individuals

• Nurse Practitioners

• Physical/Occupational Therapists in private practice

• Physicians (Doctors of Medicine or Osteopathy, Doctors of Dental Medicine; Dental Surgery; Podiatric Medicine; or Optometry)

• Physician Assistants

• Psychologists practicing independently

• Registered Dietitians or Nutrition Professionals

• Speech-Language Pathologists

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PhysOther_FactSheet_ICN903768.pdf 24

Medicare Part C

Must provide enrollees with all Part A and Part B services

May also provide Part D

Rules on relationships with providers• Interfering with patient/provider relationship• Incentives to providers• Inclusion/exclusion of providers• Cost sharing

CMS Call Letter

www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/


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Medicare Part D

• Governed by the CMS Call Letter– https://www.cms.gov/medicare/health-

plans/medicareadvtgspecratestats/downloads/announcement2016.pdf

• CY 2016 Medication Therapy Management Program Guidance and Submission Instructions Memo

– https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Memo-Contract-Year-2016-Medication-Therapy-Management-MTM-Program-Submission-v-040715.pdf

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Payer Site/typeCoding• Services• Disease

Forms Rules

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Language of Medicare Reimbursement代码

Medicare Coding System• HCPCS (Healthcare Common Procedure Coding

System)• Level 1 – CPT (Current Procedural Terminology codes)

• 5 numeric digits ex. 99605• Level 2 – Codes for product supplies and services not

covered under CPT (ambulance and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's)• Single alphabetical letter followed by 4 numeric digits

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Level 2 HCPC codes• A-codes: Transportation, Medical

Supplies, Misc.& Experimental

• B-codes: Enteral & Parenteral tx

• C-codes: Temporary Hospital Outpatient Prospective Payment System

• D-codes: Dental Procedures

• E-codes: Durable Medical Equip. (DME)

• G-codes: Temporary Procedures & Professional Services

• H-codes :Rehabilitative Services

• J-codes: Drugs Administered Other Than Oral Method, Chemotherapy Drugs

• K-codes: Temporary Codes for DME Regional Carriers

• L-codes: Orthotic/Prosthetic Procedures

• M-codes: Medical Services

• P-codes: Pathology and Laboratory

• Q-codes: Temporary Codes

• R-codes: Diagnostic Radiology Services

• S-codes: Private Payer Codes

• T-codes: State Medicaid Agency Codes

• V Codes: Vision/Hearing Services

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APC (Ambulatory Payment Classifications) Codes

Pays for most clinic and emergency department visits

Outpatient payment groups based on HCPCS codes• Similar clinical services • Similar resource consumption

APC for Outpatient E/M service’• Describe use of space and supplies• Describe involvement of hospital employees• APC code 5012 (was 0634) with HCPCS code G0463

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CPT: Current Procedural Terminology codes

Nomenclature to report medical services & procedures for payment

Maintained and owned by the AMA

Category 1 ( 3 categories)

• Evaluation and management (E&M): 99201–99499• Example 99211 incident to code

• Anesthesia: 00100–01999; 99100–99150• Surgery: 10000–69990• Radiology: 70000-79999• Pathology and laboratory: 80000–89398• Medicine: 90281–99099; 99151–99199; 99500–99607

• Example 99605–99607 medication therapy management services


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Resource-based Relative Value Scale (RBRVS)

• A system for describing, quantifying, and reimbursing physician services relative to one another.

• three components of physician services– physician work (time, technical skill & effort, judgment & stress)

– practice expense (rent, wages)

– professional liability insurance

• Relative value unit (RVU) is assigned to each

• RVU’s are determined by AMA Committee from physician survey and passed on to CMS to approve and adopt

• Must be budget neutral

• Based on Conversion factor that estimates the sustainable growth rate (SGR) and Geographic Practice Cost Index

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Why are RVUs important

Work RVU x GPCI

Practice expense RVU x GPCI

Prof liability RVU X GCPI

Total RVU.

Total RVU conversion factor

$$ for a CPT code.

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ICD-10 Codes: International Classification of Diseases, 10th Revision

• For classifying diagnoses and reason for visits in all health care settings.

• Codes may be 3, 4, 5, 6 or 7 alpha/numeric characters

• Code or codes from A00.0 through T88.9, Z00-Z99.8

• 69,000 codes

NPI number: National Provider Identifier• a unique 10-digit identification number issued to health

care providers

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What you did: CPT

code

Why you did it:

ICD 10

Who did it: NPI

number

Coding for billing

RVUS

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Payer SiteCoding• Services• Disease

Forms Rules

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Language of Forms формы

• Health Care Financing Administration 1500 form (HCFA 1500)

– The official standard form used by individual health care providers (e.g., physicians, nurse practitioners) when submitting bills or claims for reimbursement to payers

– Primarily a federal government form, but used universally

• Uniform billing (UB 92- old) and the updated UB-04 also called the CMS-1450 (new)

– i. Form used by facilities or institutions (e.g., hospitals, long-term care facilities) when submitting bills

– Government payers use UB-04, but some private payers may still use UB-92.


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HCFA 1500

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1500.pdf

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CMS-1450

http://www.amazon.com/1450-Medical-Billing-forms-Sheets/dp/B005TOD6YY

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Payer SiteCoding• Services• Disease

Forms Rules

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CMS General Rules

• “Medically necessary” as “services or supplies that are proper and needed for the diagnosis or treatment of a medical condition and are provided for the diagnosis, direct care, and treatment of the medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of the patient or the provider”

• “Usual /Customary/Reasonable” is the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.

https://www.healthcare.gov/glossary//

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Billing OpportunitiesMedicare Part A

• Governed by HOPPS regulations• Hospital bills• Billing codes: “facility fee” APC 5012, G0463• Chronic Care Management APC 5011, CPT 99490

Medicare Part B• Governed by PFS (Physician Fee Schedule) regulations• E&M codes

• “Incident to codes” 99211-99215 • TOC (Transition of Care) 99496, 99495• CCM (Chronic Care Management) 99490

• HCPC Level 2 codes• AWV (Annual Wellness Visits) G0438, G0439• Diabetes Education G0108, G0109

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Billing Opportunities

Medicare Part C• Relationship/contracting with Commercial Payer

Medicare Part D• Relationship/contracting with PDP• MTM codes

Commercial or Private Payer• Like Medicare• Relationship/contracting


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Key Points

• Understanding the ontology of billing (language, definitions and their interrelationships) will greatly aid pharmacist providers of patient care services in understanding billing opportunities.

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Identify the key billing decision makers and their influence on pharmacist

billing servicesSandra Leal, PharmD, MPH, CDE, FAPhA

Vice President for Innovation | SinfoniaRx

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Disclosures• Sandra Leal declares no conflicts of interest, real or

apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.


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Federal Policy Guidance

• Centers for Medicare and Medicaid Services (CMS)– Regulations: CMS periodically issues regulations

• Notice of Proposed Rulemaking (NPRM): Proposes policy and solicits public comment. All rules must be published in the Federal Register to notify the public and to give opportunity to comment.

• Interim Final Rule with Comment: Goes into effect when published but open for public comment for a specific period of time and then potentially revises and issues a Final Rule.

• Final Rule: Takes comments into consideration and formally codify policies that were proposed.

Source: Medicaid.gov; http://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html

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Medicare Parts

• Original Medicare– Part A: Hospital payment for inpatient, skilled nursing care, home

health care and hospice care– Part B: Medical insurance for doctors’ services, home health and

durable medical equipment

• Part D: Prescription drug coverage offered by private companies that have contracted with Medicare

• Medicare Supplement: Secondary health insurance policies offered by private companies to help pay for gaps

• Part C aka “Medicare Advantage”: A, B and sometimes D plus other benefits

Source: CMS; https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html

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Medicare Administrative Contractors (MACs)• CMS uses MACs

– To process Medicare claims

– Enroll health care providers in the Medicare program

– Educate providers on Medicare billing requirements

– Handle claims appeals

– Answer beneficiary and provider questions

– Section 1861 of the Social Security Act defines items and services for which Medicare “may” pay

Source, CMS; https://www.cms.gov/medicare/medicare-contracting/medicare-administrative-contractors/macjurisdictions.html


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Find Your MAC

Source: CMS; https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/#zpic

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Resources

• Physician Fee Schedule (PFS)

– Physician Fee Schedule Look-Up Tool

– Link: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx

• Medicare Learning Network– Education, information, and

resources for the health care professional community

• Articles• Web-Based Training• Calls and more

– Link: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html?redirect=/mlngeninfo

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Source: CMS; https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/#zpic

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Medicare versus Medicaid

• Medicare is a federal program that provides health coverage if you are 65 or older or have a severe disability, no matter your income.

• Medicaid is a state and federal program that provides health coverage if you have a very low income.

• If you are eligible for both Medicare and Medicaid (dual eligible), you can have both. Medicare and Medicaid will work together to provide you with very good health coverage.

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Medicaid

• Medicaid: Jointly funded by the federal government and the state

• Federal government pays states for a specified percentage of program expenditures called the Federal Medical Assistance Percentage (FMAP)

• FMAPs adjusted every 3 years; range 50% to 75% with an average of 57%

• States can establish their own Medicaid provider payment rates within federal requirements

• States generally pay for services through fee-for-service or managed care arrangement

Source: Medicaid; http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/financing-and-reimbursement.html

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Medicaid Benefits

• States establish and administer their own Medicaid programs and determine the type, amount, duration and scope of services within the broad federal guidelines.

• Mandatory benefits are required

• Option benefits available like prescription drugs, physical therapy, podiatry services, dental services, etc.

Souce: Medicaid; http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/medicaid-benefits.html


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Medicare versus Commercial

• Medicare is designed to absorb risk

• Commercial is required to protect its business interests– Risk depends on contractual obligations, state laws

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Local

• Compliance Officer/Billing Department

• Board

• Academia

• Physicians

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2014 Payer Mix in the United States

Employer50%

Non-Group6%

Medicaid19%

Medicare13%

Other Public2%

Uninsured10%

PERCENTAGE

Source: The Henry J. Kaiser Family Foundation: http://kff.org/other/state-indicator/total-population/

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Issues to Consider

• Medicare’s path to risk-based payment– Value-based contacts by 2018

– Transition 90% of any remaining fee-for-service Medicare payment to pay-for-performance

– Value-Based Purchasing, Readmission Reduction Programs, Bundling Payments are leading to more risk

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Population Health

• Accountable Care Organizations

• Employee groups

• Medicare Advantage plans

• Commercial markets

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Consumer-driven Health Care

• More cost to the consumer

• Higher deducible plans

• Providers and systems must win consumer interest– Ease of scheduling

– Online care options, urgent care

– Affordability


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Differentiators

• Clinical Quality– Better outcomes than competitors

• Service Experience– Strong brand reputation

– High patient satisfaction

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Source: eHealth, “Health Insurance Price Index Report for the 2015 Open Enrollment Period,” March 2015, available at: www.news.ehealthinsurance.com; HealthPocket.com, “2015 Obamacare Deductibles Remain High but Don’t Grow Beyond 2014 Levels,” November 20, 2014, available at: www.healthpocket.com; Advisory Board Company interviews and analysis.

Consumers Trade Low Premiums for High Deductibles

16% 16%

30%

39%

10%

23%

34% 34%

<$1,000 $1,000-$2,999 $3,000-$5,999 $6,000+

2014 2015

2015 Enrollees Favor Higher Deductibles

Annual Deductibles as Percentage of All Individual Plans Selected on eHealth Platform, 2014-2015

Average Public Exchange Deductibles by Tier, 2015

Bronze:

Silver:

Gold:

Platinum:

$5,181

$2,927

$1,198

$243

$5,081

$2,898

$1,277

$347

20142015

20142015

20142015

20142015

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Billing CMS: Incident to Physician and Medication

Therapy Management

Gloria Sachdev, BS Pharm, PharmDPresident and CEO Employers’ Forum of Indiana

Clinical Assistant Professor, Purdue University College of Pharmacy

Adjunct Assistant Professor, Indiana University School of [email protected]

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Disclosures• Gloria Sachdev declares no conflicts of interest, real or



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Limited billing options as a

RECOGNIZED PROVIDER

Consider pharmacist billing options as an

Unrecognized Provider

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Unrecognized Provider Billing Options Depend on 3 Factors

Service Provided

Payer Mix Practice Setting

Community-based

pharmacy clinic

Physician-based

outpatient clinic

Hospital -based outpatient clinic

Employer on-site

clinic for


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Learn Billing and Be Safe ll

Billing Options All of Michigan

except DetroitCPT billing codes Practice Setting

PB=physician based HB=hospital based

2016 Medicare Payment

Diabetes self-management training

G0108 (individual visit) G0109 (group visit)

all G0108 = $51.75G0109 = $13.91

CLIA-Waived Lab variable per POC test all fixed per CPT code

Medication Therapy Management (MTM)

99605, 99606, 99607 pharmacy, employer,health plan

variable per payer

Incident to physician: Office visit in a physician-based (aka, non-hospital) clinic

99211-99215 (PB) PB 99211 = $18.9999212 = $41.9799213 = $70.4499214 = $103.9799215 = $140.38

Incident to physician:Office visit in a hospital-based (aka, hospital outpatient clinic visit)

G0463 (HB) HB G0463 = $102.12

Incident to physician:Transitional Care Management (TCM) &RPh part of team

99496 (within 7d D/C)

99495 (within 14d D/C)PB & HB

99496 = $222.89 (PB) $157.30 (HB)_______99495 = $157.83 (PB) $108.72 (HB)

CMS Annual Wellness Visit (AWV)

G0438 (initial,once/lifetime)G0439 (subseq, annual)

PBHB

PB: G0438 = $166.02HB: G0439 = $111.88

Chronic Care Management (CCM)

99490 (20 minutes/month)

PBHB

PB: $39.37 monthlyHB: $30.80 monthly

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How to look Up CMS Payment per CPT Codes Look up Professional Fee Payment Rates (determined annually, varies per region): • https://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx• Select first search option in web browser• Select “Accept”• Select PRICING INFORMATION; RANGE OF HCPCS CODES• Select SPECIFIC LOCALITY• Enter HCPC as “99211 - 99215” or any CPT code• Select modifier as “ALL MODIFIERS”; and select carrier/MAC locality (i.e.

Indiana • HIT SUBMIT

Look up Hospital Outpatient Prospective Payment (HOPPS) Facility Fee Payment Rates (determined annually, does not vary per region):

www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HospitalOutpatientPPS/Addendum‐A‐and‐Addendum‐B‐Updates.html

• Select most recent date (i.e., January 2016)

• Under “related links,” select “Addendum B”

• Read and “Accept” the agreement to access the document

• Select Excel spreadsheet

• Search under “G0463 (the corresponding APC is 5012)

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Hospital-Based Outpatient Clinic Incident to Physician

Setting: Physician outpatient clinic that is financially tied to a hospital (one tax ID number)

HospitalPhysician

Outpatient Clinic

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Physician-Based Outpatient Clinic

Setting: 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 Physician Outpatient Clinic

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Key CMS Manual Regulations for Billing Incident to Physician

• Hospital Outpatient Services, Coverage of Outpatient Therapeutic Services Incident to a Physicians Services

– Medicare Benefit Policy Manual Chapter 6, Section 20.5.2

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06.pdf

• Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service

– Medicare Benefit Policy Manual Chapter 15, Section 60.1

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf


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CMS Criteria-Billing Incident to Physician in a Hospital-Based Outpatient Clinic

1. Direct Supervision – physician or non-physician practitioner must :

• be present in the same building & immediately available• be prepared to step in and perform the service• “clinically appropriate” to supervise the service• NPP = nurse practitioner, physician assistant, clinical

nurse specialist, nurse midwife, clinical psychologist

2. Continued Physician-Patient Relationship• The patient must be an established patient• The physician must personally perform the initial service for each

new condition, make the initial diagnosis, and establish a plan of care which includes the subsequent incidental services

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3. Must be an integral though incidental part of a physician's or non-physician practitioner’s services

4. The services are of the type commonly rendered without charge or included in the physician’s bill

5. Of a type that are commonly furnished in physician’s offices or clinics

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6. Must be furnished on a physician’s or non-physician practitioner’s “order”

7. Must have employee relationship with hospital as an employee, leased employee, or independent contractor

8. Services provided are within the scope of practice for the pharmacist as dictated by the State pharmacy practice act

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Facility Fee = Technical Fee

Every time a recognized provider sees a patient in a hospital-based outpatient

clinic

Bill a Professional Fee (PF) for cognitive services

by the physician group

Bill a separate Facility Fee (FF) from the hospital for use of the exam room, costs of lights, hospital

personnel resources, etc.

In a hospital-based outpatient clinic, incident to physician services provided by a pharmacist can be billed to Medicare via facility fee only. No professional fees

are billed to a payer unless a payer recognizes pharmacists as providers.

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Hospital-Based Outpatient Clinic: How to Bill?

Using Facility Fee billing

• Fixed payment for outpatient services provided by a hospital• Single flat fee which is the same no matter

the region or length of visit• Similar concept to inpatient DRGs

• Facility Fees are overhead charges which are charged by a hospital for utilizing hospital resources to support practitioner services

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2016 CMS Facility Fee-Only Billing

CPT G-0463 billing code goes on the CMS 1450 (aka UB-04) billing claim to Medicare

The payment from Medicare is received in the form of an APC code, APC 5012 = $102.12

Patient co-pay is $20.43

Effective January 1, 2016


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Case Example Pro Forma: Hospital-Based Outpatient Clinic

Payer Mix

Medicare 70%

Medicaid 15%

Commercial 10%

Self-Pay 5%

Self-Insured Employer 0%

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Case Example continued

• New pts are seen for 60 minutes• Follow-up pts are seen for 30

minutes

Clinic structure for pharmacist-

managed BMT clinic

• Schedule 1 new pt and 6 follow-up pts per ½ day clinic

Established clinic defined as 3

months from start date

• 1 week closed for holidays• 2 pharmacists each working 0.5

FTE

Clinic has pharmacist

coverage for 51 weeks

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Case Continued: Financial Revenue Opportunity Billing Incident to Physician in a Hospital-Based Outpatient Clinic

Revenue projection for established pharmacist BMT in Michigan (except Detroit) clinic using FACILITY FEE‐ONLY BILLING. (This does not apply to physician‐based billing!)

•For ½ day clinic/wk (0.1 FTE) = 7 visits •For 5 days/wk (1.0 FTE) = 7 visits X 10 = 70 visits/wk X 51wks/yr = 3,570 visits/year max

•Assuming 10% of patient no‐show for visits = 3,213 visits

Payer Mix for 3,213 visits Facility Fee Sub‐Total

•Medicare 70% = 2,249 bill G0463 $102.12 $229,668

•Medicaid 15% = 482 bill 99212 facility fee avg $36.00 $17,352

Commercial 10% = 321 bill 99212 facility fee avg $75.00 $24,075

Self‐Pay 5% = 160 bill 99212 facility fee avg $0.00 $0.00___

TOTAL Revenue $271,095

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Physician-Based Outpatient Clinic

Setting: Physician outpatient clinic that is NOT financially tied to a hospital (the physician group owns the practice under a separate business tax ID number)

HospitalPhysician Outpatient Clinic

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CMS Physician-Based Outpatient Clinic Rules

• Pertains to Auxiliary Personnel who may be an employee, leased employee, or independent contractor of the physician….thus, must be a direct financial expenseto the physician or non-physician practitioner (NPP)

• Direct Supervision definition is different: physician or NPP must be in same “suite”

All prior Incident-to Physician

Rules apply, in addition

to:

84

CMS Physician-Based Outpatient Clinic Rules2016 Physician Fee Schedule – clarification noted in the background section regarding billing incident to physician by auxiliary personnel. It is clearly stated that the supervising provider should bill and get paid for incident to services provided by auxiliary personnel just as if the supervising provider were personally providing the service. Thus, pharmacists meeting all the incident to criteria and documentation criteria can have their services billed for using CPT 99211-99215 and paid at 100% the physician rate (or 85% of the NPP rate, if a NPP is supervising).

• Final Rule Posted in official Federal Registrar 11-16-15

– http://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf

• Pages 71065-71068 and 71372


85

Financial Revenue Opportunity billing Incident to Physician in a Physician-Based Outpatient Clinic

Revenue projection for established pharmacist clinician in a BMT clinic in Michigan (except Detroit). Bill using CPT 99211-99215 incident to physician for all payers. Can not bill 99211-99215 under pharmacist NPI unless recognized as a provider by a payer, for which payment would likely be 85% of MD rate.

• For ½ day clinic/wk (0.1 FTE) = 7 visits • For 5 days/wk (1.0 FTE) = 7 visits X 10 = 70 visits/wk X 51wks/yr =

3,570 visits/year max• Assuming 10% of patient no-show for visits = 3,213 visits

Payer Mix for 3,213 visits Reimbursement Sub-Total• Medicare 70% = 2,249 bill 99212 $41.97 $94,391• Medicaid 15% = 482 bill 99212 $15.00-guess $7,230• Commercial 10% = 321 bill 99212 $50.00-guess $16,050• Self-Pay 5% = 160 bill 99211 $0.00 $0.00___


86

Medicare Part D: Medication Therapy Management Program (MTMP)

As part of the 2003

Medicare Modernization Act (MMA),

Pharmacists as of Jan 1st 2006 are permitted for the first time to bill for

COGNITIVE SERVICES!

87

MTM Definition per CMS

A patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence. Therefore, the programs include high-touch interventions to engage the beneficiary and their prescribers.

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Memo-Contract-Year-2016-

Medication-Therapy-Management-MTM-Program-Submission-v-040715.pdf 88

Criteria Part D Sponsors Must Establish for their MTM Program

Effective Jan 1, 2016

Annualcomprehensive

medication review (CMR)

Quarterly targeted medication reviews (TMRs) with follow-

up interventions when necessary

Must auto-enroll (pt can opt-out)

MAY be furnished by a pharmacist or other

qualified provider

MAY distinguish between services in

ambulatory and institutional settings

MUST be developed in cooperation with

licensed & practicing pharmacists &

physicians

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Memo-Contract-Year-2016-

Medication-Therapy-Management-MTM-Program-Submission-v-040715.pdf

89

Minimum Requirements that can be set by a Prescription Drug Plan

Minimum Threshold Criteria for MTM

2-3 chronic health conditions

If PDP opts to target by chronic disease, then must have 5 of 9 core

chronic conditions

2-8 Part D meds Likely to incur Part D drug costs > $3,507

90

Changes from 2015 to 2016 CMS MTMP

1. Under the Provider of MTM Services, sponsors will now be able to select Pharmacy Intern Under Direct Supervision of a Pharmacist or Pharmacy Technician, if applicable.

2. Under Qualified Provider of Interactive, Person-to-Person CMR with written summaries, sponsors will now be able to select Disease Management Pharmacist and Pharmacy Intern Under Direct Supervision of a Pharmacist, if applicable.

3. Annual cost threshold = $3,507 (2015 = $3,138)


ll







all G0108 = $51.75G0109 = $13.91




variable per payer

Incident to physician: Office visit in a physician-based (aka, non-institutional) clinic

99211-99215 (PB) PB 99211 = $18.9999212 = $41.9799213 = $70.4499214 = $103.9799215 = $140.38

Incident to physician:Office visit in a hospital-based (aka, institutional) outpatient clinic

G0463 (HB) HB G0463 = $102.12




99496 = $222.89 (PB) $157.30 (HB)_______99495 = $157.83 (PB) $108.72 (HB)



PBHB

PB: G0438 = $166.02HB: G0439 = $111.88



PBHB


92

Medication Therapy Management (MTM) CPT Codes

99605 (Prior 0115T): new patient, face-to-face• Initial 15 minutes

99606 (Prior 0116T): established patient, face-to-face• Initial 15 minutes

99607 (Prior 0117T): face-to-face• For each additional 15 minutes• Used only in addition to 99605 or 99606 • List separately

93

How To Use MTMP Codes?

Case 1: New Patient Visit = 45 min

Case 2: Follow-Up Patient Visit = 30 min

94

CMS Innovation Center testing new MTM Payment Model• Part D Enhanced Medication Therapy Management (MTM)

model will test whether providing Part D sponsors with additional payment incentives will lead to improving therapeutic outcomes, while reducing net Medicare costs.

• Begins January 1, 2017 with a 5 year performance period.

• Testing new payment model: per member per month (PMPM) base, plus performance-based incentive payment set at $2.00 PMPM

https://innovation.cms.gov/initiatives/enhancedmtm/

95

CMS Innovation Center testing new MTM Payment Model• Health Plans who apply must:

(a) be an individual market stand-alone basic plan

(b) have a minimum enrollment of 2,000

(c) have existed as a basic plan for at least 3 years

(d) not be under sanction by CMS or law enforcement

(e) rank at least 3-Star (case by case basis if < 3 Star)

96

CMMI Enhanced MTM model

11 States will participate: Virginia, Florida, Louisiana, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming, and Arizona


97

References

NACDS White Paper

Oct 2015

http://avalere-health-production.s3.amazonaws.com/uploads/pdfs/1446827136_102915_Avalere_NACDS_WhitePaper_LP_04.pdf

www.pharmacist.com/sites/default/files/files/mtm_billing_tips.pdf

APhA MTM Tips for Pharmacists

98

Additional References

G-Code 2014: Hospital-Based Outpatient Clinic Facility Fee PaymentAvailable at the American Society of Health-System Pharmacist bookstore

Kliethermes MA, Brown TR, eds. Building a successful ambulatory care practice: a complete guide for pharmacists. Bethesda, MD: American Society of Health-System Pharmacists; 2012

99

CPT Codes are:

A. Level 1 HCPC (Healthcare Common Procedure Coding System) codes

B. Codes that include the “incident to” Evaluation & Management codes which providers may use to support pharmacist services

C. Used by Medicare Part B for billing purposes

D. Adjusted by the Resource-based Relative Value Scale (RBRVS)

E. All of the above

100

APC (Ambulatory Payment Classifications) Codes are used in which setting?

• Hospitals or health-systems for “facility fee” services in their ambulatory clinics

• Physician offices for diabetes education services

• Assisted living and group homes for clinical provider services

• For in-home services provided by Medicare Part B providers

101

Which one of the following statements is NOT a CMS criteria for billing incident to physician in a hospital-based outpatient clinic?

A. Must have an order/referral

B. Must have Direct Physician Supervision

C. Must have a continued physician relationship

D. Must be considered a recognized provider

102

Which of the following is a TRUE Statement?

A. MTM CPT codes can be billed under Medicare Part B

B. MTM CPT codes can be billed under Medicare Part D

C.MTM is required by Medicare to be provided by pharmacists

D.MTM is an “opt-in” requirement of Medicare prescription drug plans


103

What are key opportunities for pharmacists to comment on impending Medicare rules?

A. There is never an opportunity for pharmacists to comment on rules.

B. During the Notice of Proposed Rulemaking

C. During the Interim Final Rule

D. After the Final Rule is implement

Billing Boot Camp II


Sandra Leal, PharmD, MPH, FAPhA, CDE

Gloria Sachdev, BS Pharm, PharmD106

Billing Boot Camp II: Advanced Training

107

Disclosures• Mary Ann Kliethermes is co-owner of Clinical pharmacy

Systems Inc.

• [INSERT FACULTY NAME(S)] [INSERT THE FOLLOWING TEXT IF NO CONFLICTS EXIST: “declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.” OR LIST THE CONFLICTS ]


108

• Target Audience: Pharmacists

• ACPE#: 0202-0000-16-013-L04-P

• Activity Type: Knowledge-based


109

Learning Objectives• Describe the opportunities and billing requirements for

Diabetes Self-Management Training services.

• Describe the opportunities and billing requirements for pharmacists to participate in Medicare Annual Wellness Visits, Transitional Care Management, and Chronic Care Management services.

• Identify quality and outcome measures tied to performance payment in both fee-for-service and new care model payment strategies that can be impacted by pharmacists’ services.

• Discuss how to leverage pharmacist skills and services to design practice models that provide value in new payment models.

110

Diabetes Self-Management can be billed:

A. Any site that provides the services

B. A site accredited by AADE or ADA

C. Any providers as long as they have are a Certified Diabetes Educator (CDE)

D. On the same day they see another provider at a Federally Qualified Health Center

111

You are providing pharmacy patient care services in a primary care practice whose patient population payment source is 70% Medicare Advantage. Which of the following value based performance measures should you focus on to prove the value of your patient care services?

A. ACO 33 measures

B. HEDIS measures

C. STAR Measures

D. Hospital readmission rates

E. Universal Data Set

112

Medication Adherence measures are used in which Medicare Programs

A. Medicare Advantage and Medicare Part D prescription plans

B. Federally Qualified Health Centers and Accountable Care Organizations

C. Medicare Part D prescription plans only

D. Medicare Advantage, Medicare Part D and Health Insurance Marketplace

113

What is the FIRST step in developing a sustainable business plan,?

A. Provide a service that you like to provide.

B. Meet referring physicians and see what services they suggest.

C. Conduct a needs assessment

D. Ascertain billing options

114

Describe the opportunities and billing requirements for Diabetes Self-Management Training (DSMT) services

Sandra Leal, PharmD, MPH, CDE, FAPhA



115

Disclosures• Sandra Leal declares no conflicts of interest, real or



116

To bill the Medicare Part B program for DSMT, a number of key elements must be in place.

The DSMT Program must have:– Accreditation from AADE or ADA

– A partnership with a provider that can bill Medicare

The beneficiary must have: – A diabetes diagnosis

– A written referral for DSMT

Source: The CMS Health Disparities Pulse Resource Center; http://www.cmspulse.org/resource-center/health-topics/diabetes/documents/DSME-Toolkit.pdf

117

Accreditation Considerations

American Diabetes Association (ADA)

American Association of Diabetes Educators (AADE)

First site: $1,100 1 to 10 sites: $800

Additional sites: $100 each 11 to 20 sites: $1200

Same fee for renewal 20 sites: Contact AADE

Valid for 4 years Same fee for renewal

Annual status report required Valid for 4 years

Status update and annual reports

5% of recognized sites audited 10% of recognized sites audited

118

DSMT First Year

Codes Description Allowable Units

G0108 • Individual DSMT• Medicare allows for 1 hour• Billable in 30 minute

increments (1 unit)

2 units = 1 hour

G0109 • Group DSMT• 2 or more participants• Medicare allows 9 hours• Billable in 30 minutes

increments (1 units)

18 units = 2 hours

*CPT Codes that may be accepted by private insurers: 98960, 98961, 98962

Source: AADE, https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Diabetes_Services_Order_Form_Backgrounder__Final.pdf

119

DSMT Subsequent Years After Initial Year

Codes Description Allowable Units

G0108/G0109 • Medicare allows for any combination of 2 hours

• Billable in 30 minute increments (1 unit)

4 units = 4 hour

Source: AADE, https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Diabetes_Services_Order_Form_Backgrounder__Final.pdf

120

Codes 2015 Medicare Fee Schedule

G0108 (individual) 1 unit (30 minutes): $46.46 - $71.06

G0109 (group) 1 unit (30 minutes): $12.57 - $19.20

Source: HSAG: https://www.hsag.com/contentassets/051dd35e6100416db6b5bef77987e663/dsme_dsmt_crosswalk_20150303.pdf

Billing Codes


121

Reimbursement Example

G0108: Individual visit

$48.46 X 2 units X 8 patients = $775.36/ (8 hour day)

G0109: Group visit

$12.05 X 4 units X 8 patients = $385.60 (2 hour class)

*FQHCs can only bill G0108; not on the same day as a provider visit

122

Source: AADE, https://www.diabeteseducator.org/docs/default-source/legacy-docs/_resources/pdf/general/Diabetes_Services_Order_Form_v4.pdf

123

Describe the opportunities and billing requirements for pharmacists to participate in Medicare Annual

Wellness Visits, Transitional Care Management Services, and Chronic

Care Management

Sandra Leal, PharmD, MPH, CDE, FAPhA


124

Initial Preventative Physical Exam (IPPE) and Annual Wellness Visits (AWV)

• CMS added IPPE and AWV codes to the physician fee schedule in 2011

125

Initial Preventative Physical Exam (IPPE) and Annual Wellness Visits (AWV)

Visit Type Frequency Billing Elements

Welcome to Medicare (IPPE)

Within first 12 months of initial Medicare Part B coverage

• Only primary care provider can bill

•No copay/coinsurance

• History: Medical and social,screening for depression/mood disorders, functional ability and safety evaluations

• Examination: Assessment and end-of-life planning

• Counseling and Education: Including written plan

126

Visit Type Frequency Billing Elements

Initial Annual Wellness Visit

Not within first 12 months of initial Medicare Part B coverage

• Pharmacist“incident to” a provider request*

• No copay/coinsurance

• History: Same asIPPE

• Examination: Same as IPPE but no mention of end-of-life planning, list of current healthcare providers and suppliers

• Counseling and Education: Written screening schedule, interventions and health advise, referral to health education and preventive counseling services

*FQHCs do not utilize “incident to” for this service as they reimburse with the Prospective Payment System (PPS) therefore pharmacists can not initiate an AWV as they are not recognized providers in an FQHC.


127

Key Points

• Prevention visits, not an annual physical

• Separate evaluation and management (E/M) and medically necessary services can be billed at the same time as an IPPE or AWV with a modifier - 25

128

Billing Codes

Codes Billing Code Descriptors Non-Facility Price

G0438 AWV; includes a personalized prevention plan of service (PPPS), initial visit

~$174.28

G0439 AWV, includes a personalized prevention plan of service (PPPS), initial visit, subsequent visit

~$117.86

Source: CMS, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf

129

Implementation considerations…

• Time burden

• Recruitment of patients

• FQHC issues

130

Transitional Care Management (TCM) Services• CMS added TCM codes to the physician fee schedule in

2013– 99495 and 99496

• Complex requirements

131

Who Qualifies

Inpatient Setting Community Setting

Acute Care Hospital Home

Psychiatric Hospital Domiciliary

Long Term Care Hospital Rest Home

Skilled Nursing Facility Assisted Living

Rehabilitation Facility

Hospital Outpatient Observation or Partial Hospitalization

Partial Hospitalization at a Community Mental Health Center

Source: Medicare Learning Network. Transitional Care Management Services. 2013; ICN908628

132

Requirements

• Within 2 business days of discharge, contact with patient or caregiver.

• If unsuccessful, document 2 attempts.

• General supervision “incident to” applies; same location requirement at same time not necessary


133

Things to know…

• Physician

• Non-physician practitioners (NPP): certified midwives, clinical nurse specialists, nurse practitioners, physician assistants

• Claim submission must be 30 days from discharge date

• Not paid if patient is readmitted before the 30 days

134

Things to consider…

• Can be performed ”incident to” with general supervision

135

Where do you fit in?

• Can provide the non face-to-face components

• Mandatory medication reconciliation requirement

• Other elements in team-based care

136

Face-to-face codes

• 99495

• Moderate medical decision making

• Within 14 days of discharge

• 99496

• High medical decision making

• Within 7 days of discharge

137

Billing Codes

Codes Non-Facility Price

99495 $166.37

99496 $233.57

Source: CMS, https://www.cms.gov/apps/physician-fee-schedule/

138

Implementation considerations…

• Identification of patients being discharged from hospitals

• Difference in claim submission dates


139


• Introduced January 2015 Physician Fee Schedule• As of 11/15 only 26% of eligible providers had launched

CCM programs• 23% intended to do so in the next 12 months• 11% had no plans to participate in the next 12 months• Early struggles:

– Physician engagement– Patient education– Efficient processes– Regulatory compliance

Source: The National Chronic Care Management Survey, http://www.pyapc.com/chronic-care-management-survey-released/

140

Who Qualifies?

Source, CMS: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

Chronic Care Management Service

Multiple (2 or more) chronic conditions expected to last 12 months, or until the death of a patient

Chronic condition that places the patient at significant risk of death, acute exacerbation/decompensation or functional decline,

Comprehensive care plan established, implemented, revised or monitored.

141

Practitioners Eligible

• Physicians• Non-physician practitioners (NPP)

– Certified Nurse Midwives– Clinical Nurse Specialists– Nurse Practitioners– Physician Assistants

142

Requirements

• Patient Agreement– Patient Consent

• Inform the patient of the availability of the CCM service and obtain written agreement to have the services provided, including authorization for the electronic communication of medical information with other treating practitioners and providers

• Explain and offer the CCM service to the patient. In the patient’s medical record, document this discussion and note the patient’s decision to accept or decline the service

• Explain how to revoke the service.

• Inform the patient that only one practitioner can furnish and be paid for the service during a calendar month

• Cost-sharing

143

Requirements

• Scope of Services Elements– Structured Data Recording using a certified EHR

– Comprehensive Care Plan

– Access to Care: Ensure 24/7 access

144

Things to consider…

• Can be performed ”incident to” with general supervision


145

Key Points

• A sustainable practice will likely require the use of several of these codes

• Know your payer mix

• Consider front end and back end payments based on a blend of different contracts

• Negotiation is constant with internal and external players

• Stay informed

146

Who are you beholding to?

Choosing Quality Measures


Vice-Chair, Professor

Chicago College of Pharmacy

Midwestern University

147

Learning Objective

• Identify quality and outcome measures tied to performance payment in both fee-for-service and new care model payment strategies that can be impacted by pharmacists’

148

Triple AimReducing per-capita costs

Better health for populations

Better care for individuals

Health Care

Reform

149

CMS Quality Strategy 2016

• Goal 1: Make care safer by reducing harm caused in the delivery of care.

• Goal 2: Strengthen person and family engagement as partners in their care.

• Goal 3: Promote effective communication and coordination of care.

• Goal 4: Promote effective prevention and treatment of chronic disease.

• Goal 5: Work with communities to promote best practices of healthy living.

• Goal 6: Make care affordable.

http://www.ahrq.gov/workingforquality/agencyplans/2016-cms-agency-specific-plan.pdf

150

IOM Vital Signs Core MeasuresMeasuring what matters to patients

Am I healthier? Do I feel better to the level where I can

function as I desire?

Did your care make me sicker?

Can I reach you when I need you?

Can I afford this

care?


151

Whose measures should we care about?

Federal Medicare

Part A

Part B

Part C

Part D

State

Medicaid

Insurance exchanges

Commercial or Private

Employer based

Group

Individual

152

Medicare Part AHospital Readmissions Reduction Program’’ (ACA)

• ‘‘Base operating DRG payments’’ are reduced by a hospital-specific adjustment factor that accounts for the hospital’s excess readmissions

• ‘‘Excess readmissions ratio’’ - risk-adjusted readmissions based on actual readmissions

• Look up: http://cdn.kaiserhealthnews.org/attachments/MedicareReadmissionPenaltiesByHospital,Year4.pdf

153

Hospital Readmission Program (ACA)

Conditions that apply• AMI• HF • Pneumonia• Chronic obstructive pulmonary disease (COPD)• Elective primary total hip and/or total knee arthroplasty (THA/TKA)• Coronary Artery Bypass Graft (CABG) - in 2017

Penalties• 0 to 3%• In 2016 - 2,592 hospitals will receive lower payments for every Medicare patient

that stays in the hospital • Rural, non-teaching, less than 100 beds fair the worst

154

Medicare Part B: Fee for Service

• Physician Quality Reporting System (PQRS)– https://www.cms.gov/medicare/quality-initiatives-patient-

assessment-instruments/pqrs/measurescodes.html

• Meaningful Use– https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequirements.html

155https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html 156


157

Stage 2 Meaningful Use (2015-2017)

Protect Patient Health Information

Clinical Decision Support

CPOE

Electronic Prescribing (eRx)

Health Information Exchange

Patient Specific Education

Medication Reconciliation

Patient Electronic Access (VDT)

Secure Messaging (EPs only)

Public Health and Clinical Data Registry Reporting

Medication Reconciliation:medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care

Public Health and Clinical Data Registry Reporting:

(immunization and others)

158

Stage 3 Meaningful Use (2018)

Protect Electronic Health Information

Electronic Prescribing (eRx)

Clinical Decision Support

Computerized Provider Order Entry (CPOE)

Patient Electronic Access to Health Information

Coordination of Care through Patient Engagement

Health Information Exchange

Public Health Reporting .

https://www.cms.gov/eHealth/downloads/Webinar_eHealth_May11_ONCStage3.pdf

159

Medicare Shared Savings ACO

434 ACOs in 49 states as of 2016

• 100 new for 2016

Showed improvement in 27 of the 33 measures

18 of the 22 measures that are similar are in the PQRS, the Shared Savings ACO had better results

28% held spending below targets

• 37% if an ACO since 2012

John Pilotte, Dir. Performance-Based Payment Policy Group, CMSAPM Framework Webinar, HCPLAN Payment Network 1/12/16

160

ACO–33 Quality MeasuresPatient Experience - 7 measures CAHPS

• Education

Care Coordination and Patient Safety - 6 measures• Hospital readmissions• Admissions for COPD and Heart Failure • Med reconciliation

Preventive Health – 8 measures• Pneumococcal and Influenza vaccination• Obesity, Smoking• Depression, BP

At Risk Populations – 12 measures• DM: HgA1c, LDL, BP, ASA, smoking• HTN: BP• Ischemic Vascular Dx (IVD): LDL, ASA or anti-thrombotic• HF: beta-blocker• CAD: LDL lowering, ACE/ARB

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Quality_Factsheet_ICN907407.pdf

161

Federally Qualified Health Centers

FQHCs are “safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless

162

Universal Data Set – HRSA

Adult weight screening (BMI) and follow up

Tobacco use and cessation

Appropriate Asthma therapy

Lipid lowering therapy for CAD

ASA for AMI, CABG, PTCA or IVD

http://www.bphc.hrsa.gov/datareporting/reporting/2015udsmanual.pdf


163

Medicare Part C “Medicare Advantage”Medicare Part D “Prescription Drug Plan

• Rules based on CMS Call letter (every spring)

• Quality determined by Star Measures

164

Star Ratings CMS: Plan Evaluation

Part C Domains1. Staying healthy –

prevention

2. Managing Chronic Conditions

3. Member experience

4. Member complaints and changes in performance

5. Customer Service

Part D Domains1. Drug plan customer

service

2. Complaints, access problems and improvement

3. Member Experience

4. Drug Pricing and Patient Safety

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/index.html?redirect=/PrescriptionDrugCovGenIn/06_PerformanceData.asp

Ratings displayed as 1-5 stars1.★ = poor performance

2.★★ = below average performance3.★★★ = average performance

4.★★★★ = above average performance5.★★★★★ = excellent performance

165

Star ratings – cut points/bonus

http://www.cms.gov/Medicare/Prescription-Drug-overage/PrescriptionDrugCovContra/Downloads/Announcement2012final.pdfhttp://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2015.pdf

Star Rating QBP Percentage for 2012/2013

QBP Percentagefor 2014

QBP Percentage for 2015

QBPPercentage For 2015

Less than 3 stars

0% 0% 0% 0%

3 stars 3% 3% 0% 0%

3.5 stars 3.5% 3.5% 0% 0%

4 stars 4% 4% 5% 5%

4.5 stars 4% 5% 5% 5%

5 stars 5% 5% 5% 5%

166

Measures to Care About – Medicare C

Staying Healthy: Screenings, Tests and Vaccines

• C01 - Breast Cancer Screening • C02 - Colorectal Cancer Screening • C03 - Annual Flu Vaccine • C04 - Improving or Maintaining Physical Health• C05 - Improving or Maintaining Mental Health• C06 - Monitoring Physical Activity• C07 - Adult BMI Assessment

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Star-Ratings-Request-for-Comments.pdf

167


Managing Chronic (Long Term) Conditions

• C01 - SNP Care Management• C09 - Care for Older Adults – Medication Review• C10 - Care for Older Adults – Functional Status Assessment• C11 - Care for Older Adults – Pain Screening• C12 - Osteoporosis Management in Women with a Fracture• C13 - Diabetes Care – Eye Exam• C14 - Diabetes Care – Kidney Disease Monitoring• C15 - Diabetes Care – Blood Sugar Controlled• C16 - Controlling Blood Pressure• C17 - Rheumatoid Arthritis Management• C18 - Reducing the Risk of Falling• C19 - Plan All-Cause Readmissions

168


Member Experience with Health Plan

• C20 - Getting Needed Care• C21 - Getting Appointments & Care

Quickly• C22 - Customer Service• C23 - Rating of Health Care Quality• C24 - Rating of Health Plan• C25 - Care Coordination.


169

Measures to Care About – Medicare DDrug Safety and Accuracy of Drug Pricing

•

• D10 - MPF Price Accuracy• D11 - High Risk Medication• D12 - Medication Adherence for Diabetes

Medications• D13 - Medication Adherence for Hypertension

(RAS Antagonists)• D14 - Medication Adherence for Cholesterol

(Statins)• D15 - MTM Program Completion Rate for CMR

170

State: Health Insurance Marketplace or State ExchangesState’s subsidized health insurance for those without

Assistance for small businesses “the SHOP” (Small Business Health Options Program

Cost assistance for those at 400% FPL

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2016-QRS-Measure-Technical-Specifications.pdfhttp://obamacarefacts.com/state-health-insurance-exchange/

171

States Status in the Marketplace

http://www.commonwealthfund.org/interactives-and-data/maps-and-data/state-exchange-map172

NCQA (HEDIS) Measures• Adult BMI Assessment

• Annual Monitoring for Patients on Persistent Medications

• Antidepressant Medication Management

• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

• Comprehensive Diabetes Care: Eye Exam (Retinal)

• Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)

• Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing

• Comprehensive Diabetes Care: Medical Attention for Nephropathy

173

NCQA (HEDIS) Measures• Controlling High Blood Pressure

• Follow-Up After Hospitalization for Mental Illness (7-Day Follow-Up)

• Follow-Up Care for Children Prescribed ADHD Medication

• Human Papillomavirus Vaccination for Female Adolescents

• Immunizations for Adolescents (Combination 1)

• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

• Medication Management for People With Asthma (75% of Treatment Period)

• Plan All-Cause Readmissions

174

Pharmacy Quality Alliance Measures

Medication Adherence for Diabetes Medications

Medication Adherence for Hypertension (RAS Antagonists)

Medication Adherence for Cholesterol

PDC = Proportion of Days Covered


175

State and Commercial Payers

Variable

May be contractual

Commercial primarily HEDIS Measures• NCQA National Committee for Quality Assurance

• Accreditor for Health Insurance Companies and Physicians• HEDIS Healthcare Effectiveness Data and Information Set

• 81 measures• 5 domains

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Example of a Commercial Payer• Upper Eastern NY Health Plan

• Use a risk adjusted global payment at 40% above the typical FFS payment

• 20% bonus based on triple aim– 4 categories of HEDIS measures

– CHAPS survey

– Utilization measures

• Hospitalization, ER visits

• Medication use

• Lab and imaging use

• Specialists

– Netted $17 PMPM for 2014

Eileen Wood from Capital District Physicians' Health Plan APM Framework Webinar, HCPLAN Payment Network 1/12/16

177

Key Points

• Choose measures that matter to PATIENTS!

• Keep in mind national quality goals

• What quality measures you should focus on DEPENDS!

• Who are you doing business with?

• Who is paying the bill for the patients you are seeing?

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Value Proposition Considerations

Gloria Sachdev, BS Pharm, PharmDPresident and CEO Employers’ Forum of Indiana

Clinical Assistant Professor, Purdue University College of Pharmacy

Adjunct Assistant Professor, Indiana University School of [email protected]

179

Disclosures

Gloria Sachdev declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.


180

Objective

Discuss how to leverage pharmacist skills and

services to DESIGN practice models that provide VALUE

in new payment models


Strategic Plan for SustainabilityConduct an Environmental Scan - focusing on a Needs Assessment

Conduct a SWOT Analysis

Conduct a Gap Analysis and Feasibility Analysis

Consider Financial Opportunities

Consider Interest of Stakeholders - Send Out The Feelers

Develop a Business Plan

Implement the Service • Billing• Legal• Operations• Policy & Procedures

Measure Outcomes! 182

CMS Provides Financial Incentives to achieve the Triple Aim: Improve Care, Improve Quality, and Reduce Costs

ACOAccountable Care Org

HRRP Hospital

Readmission Reduction

Program

VBPValue Based

Purchasing

HAC Hospital Acquired Conditio

n Reductio

n Program

MU Meaningful Use of the

Electronic

Medical Record

PQRS Physician

Quality Reporting System

PCMH Patient

Centered Medical Home

5 Star Ratings

Health Plans

Needs Assessment

Hospitals ACO HRRP VBP MU HAC

Physician practices

ACO PQRS PCMH MUPhysician compare

Health Plan 5‐star ratingsTotal health care

costs

Self‐Insured Employer

Employee wellness

Employee disease mgmt

Total health care costs

Nursing Homes

Nursing home compare

Community Pharmacies

Community pharmacy practice accreditation

CMS data publically available184

Sustainable Pro Forma Considerations

Cost-Savings &

Cost Avoidance

• HRRP - 3% penalty• VBP - 1.5% • HAC (FY 2015) – 1%• MU (CY 2015) – 1%• PQRS (FY 2015) – 1.5%

P4P: Pay-for-

Performance

• ACO • PCMH• 5-Star Ratings• VBP• Local payer P4P

Revenue • Billing for services

BUSINESS PLAN

Integrated or Con

tractual

CMS Programs Web Site

Hospital Readmission Reduction Program

www.checkmypenalty.com

https://www.medicare.gov/hospitalcompare/readmission‐reduction‐program.html

Health Plan Compare (using 5‐star ratings)

www.medicare.gov/find‐a‐plan/questions/home.aspx

Accountable Care Organizations https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/sharedsavingsprogram/ACOs‐in‐Your‐State.html

https://www.medicare.gov/physiciancompare/aco/search.html

Physician Compare

https://data.medicare.gov/Hospital CompareNursing Home CompareDialysis Facility CompareHome Health Compare

Hospital Value‐Based Purchasing

https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/hospital‐value‐based‐purchasing/index.html?redirect=/Hospital‐Value‐Based‐Purchasing/

https://www.medicare.gov/HospitalCompare/Data/payment‐adjustments.html

Hospital‐Acquired Condition Reduction Program

https://www.medicare.gov/hospitalcompare/HAC‐reduction‐program.html

Needs Assessment

CMS HRRP: Hospital Readmission Reduction Program

GOAL = lower 30‐day hospital readmissions

FY 2013 penalty max 1% per Medicare claim Heart Failure, Pneumonia, AMI

FY 2014 penalty max 2%

FY 2015 penalty max 3%

*Added 2 more measures: COPD, TKA/THA

http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html/

Sachdev, G. Sustainable business models: systematic approach toward successful ambulatory care pharmacy practice. Am J Health-Syst Pharm, 71, Aug 15, 2014:1266-1374. Figure 2


Which Hospitals are in the Red from Hospital Readmission Reduction Program?

• http://cdn.kaiserhealthnews.org/attachments/MedicareReadmissionPenaltiesByHospital,Year4.pdf

188

CMS Hospital Readmission Reduction Program

http://www.healthrecoverysolutions.com/penalty.php

189

Hospital Medicare Readmission PenaltyArkansas Methodist Medical Center

www.checkmypenalty.com accessed 11-5-15

CHF 254 patientsAMI 166 patientsPNM 391 patientsHIP/KNEE 76 patientsCOPD 317 patients

190

Hospital Medicare Readmission PenaltyArkansas Valley Regional Medical Center

CHF 254 patientsAMI 166 patientsPNM 391 patients

HIP/KNEE 76 patientCOPD 317 patients

191

ACO’s in Arkansas

Accessed 11-5-15, www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/ACOs-in-Your-State.html

# 6-14

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Articulate Value Proposition

Increase # of Patients achieving therapeutic goals

Increase Revenue potential for physicians

Increase Revenue potential for clinic • Ordering more labs• Ordering more Rx and DME

Increase Access to patient care

Increase Revenue/Cost Savings per pharmacist service• Direct Billing• Cost Savings• Pay-for-Performance


193

Pro Forma (financial projection) Determinants

What are the GAPS in care (needs assessment results)

WHAT types of services are available to close gaps identified

WHERE is the service located • Place of Service (POS) 22 - hospital based outpatient clinic• POS 11 - physician based outpatient clinic• POS 1 - retail pharmacy

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Pro Forma (financial projection) Determinants continued

WHO will provide supervision

• Billing incident to physician services (direct supervision)

• Billing TCM and CCM (general supervision)

HOW many patients can be seen per day

WHAT is projected no-show rate

ll







all G0108 = $51.75G0109 = $13.91




variable per payer

Incident to physician: Office visit in a physician-based (aka, non-hospital) clinic

99211-99215 (PB) PB 99211 = $18.9999212 = $41.9799213 = $70.4499214 = $103.9799215 = $140.38

Incident to physician:Office visit in a hospital-based (aka, hospital outpatient clinic visit)

G0463 (HB) HB G0463 = $102.12




99496 = $222.89 (PB) $157.30 (HB)_______99495 = $157.83 (PB) $108.72 (HB)



PBHB

PB: G0438 = $166.02HB: G0439 = $111.88



PBHB


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Case Example Pro Forma: Physician-Based Outpatient Clinic

Payer Mix

Medicare 70%

Medicaid 15%

Commercial 10%

Self-Pay 5%

Self-Insured Employer 0%

197

Case Example continued

• New pts are seen for 60 minutes• Follow-up pts are seen for 30

minutes

Clinic structure for pharmacist-

managed BMT clinic

• Schedule 1 new pt and 6 follow-up pts per ½ day clinic

Established clinic defined as 3

months from start date

• 1 week closed for holidays• 2 pharmacists each working 0.5

FTE

Clinic has pharmacist

coverage for 51 weeks

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Financial Revenue Opportunity billing Incident to Physician in a Physician-Based Outpatient Clinic

Revenue projection for established pharmacist clinician in a HF clinic in Michigan (except Detroit). Bill using CPT 99211-99215 incident to physician for all payers. Can not bill 99211-99215 under pharmacist NPI unless recognized as a provider by a payer, for which payment would likely be 85% of MD rate.

• For ½ day clinic/wk (0.1 FTE) = 7 visits • For 5 days/wk (1.0 FTE) = 7 visits X 10 = 70 visits/wk X 51wks/yr =

3,570 visits/year max• Assuming 10% of patient no-show for visits = 3,213 visits

Payer Mix for 3,213 visits Reimbursement Sub-Total• Medicare 70% = 2,249 bill 99212 $41.97 $94,391• Medicaid 15% = 482 bill 99212 $15.00-guess $7,230• Commercial 10% = 321 bill 99212 $50.00-guess $16,050• Self-Pay 5% = 160 bill 99211 $0.00 $0.00___



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Final Thoughts…

The growth of ambulatory care pharmacist services depends on practice leaders being able

to clearly articulate the value proposition for these services in the context of the prevailing

health care payment and delivery systems

200

Thank You

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Diabetes Self-Management can be billed:

A. Any site that provides the services

B. A site accredited by AADE or ADA

C. Any providers as long as they have are a Certified Diabetes Educator (CDE)

D. On the same day they see another provider at a Federally Qualified Health Center

202

You are providing pharmacy patient care services in a primary care practice whose patient population payment source is 70% Medicare Advantage. Which of the following value based performance measures should you focus on to prove the value of your patient care services?

A. ACO 33 measures

B. HEDIS measures

C. STAR Measures

D. Hospital readmission rates

E. Universal Data Set

203

Medication Adherence measures are used in which Medicare Programs

A. Medicare Advantage and Medicare Part D prescription plans

B. Federally Qualified Health Centers and Accountable Care Organizations

C. Medicare Part D prescription plans only

D. Medicare Advantage, Medicare Part D and Health Insurance Marketplace

204

What is the FIRST step in developing a sustainable business plan,?

A. Provide a service that you like to provide.

B. Meet referring physicians and see what services they suggest.

C. Conduct a needs assessment.

D. Ascertain billing options.

Billing Boot Camp I: Basic Training -...

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