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Challenges Faced in Developing a Billable Clinical Service

Alvin Godina, PharmD, BCPS, BCACPClinical Pharmacy Specialist – Rush University Medical Center

Tomasz Jurga, PharmD, BCPS, BCACP, CDCESClinical Pharmacy Specialist – Mount Sinai Hospital

Conflict of Interest

• Neither speaker has conflicts of interest to disclose regarding the subject matter presented here today

Objectives

1. Describe the role of pharmacists in providing patient care in the ambulatory care setting.

2. List key players of hospital/health systems that contribute to establishing a billable service.

3. Identify challenges in developing billable services & methods to address and resolve said challenges.

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Pre-test Question 1 - Reflection

Which of the following roles best represent pharmacist services in the ambulatory care setting?

A. Inpatient order verification

B. Medication therapy management

C. Aminoglycoside dose adjustment

D. Medication procurement and dispensing

Pre-test Question 2 - Reflection

Billing & compliance officers are primarily concerned with which of the following?

A. Processes to prevent risk

B. Following regulation of payers

C. Quality of clinical service

D. Use of correct billing codes

Pre-test Question 3 - Reflection

Which of the following provides a summary of clinical operations, policies & procedures intended to guide your clinic?

A. Service model proposal

B. SWOT analysis

C. Billing Structure

D. CMS rule & regulation

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Ambulatory Care Pharmacy Practice

• Provision of health care services that are integrated and accessible.

• Pharmacists are accountable for: • Addressing medication needs,

• Developing sustained partnerships with patients,

• Practicing in the context of family and community.

• Ambulatory care pharmacists may work in both an institutional and community-based clinic involved in direct care of a diverse patient population.

Helling DK, Johnson SG. ASHP Ambulatory Care Conference and Summit. 2014

Ambulatory Care Pharmacy Practice

• Direct patient care

• Medication therapy management, • Nowadays we want focus on comprehensive medication management

• Long-term relationships,

• Coordination of care,

• Patient advocacy,

• Promotion of health and wellness,

• Triage and referral,

• Patient education and self-management. Helling DK, Johnson SG. ASHP Ambulatory Care Conference and Summit. 2014

Ambulatory Care as a Board Specialty

• Board Certified Ambulatory Care Pharmacist (BCACP) reflects increased need for pharmacists working in this field

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Patient-Care Services: Implementation of Pharmacists• Anticoagulation

• Hypertension

• Endocrinology• Diabetes

• Cardiovascular

• Heart failure

• Chemotherapy

• Examples are truly endless: pharmacists can perform any duty as defined in a collaborative practice agreement.

Patient-Care Services:Implementation of Pharmacists• There is no standard on how to perform ambulatory care services

• There is no standard on how to implement pharmacists into a multidisciplinary team.

• Multiple recommendations exist on types of services that can be performed, examples include:• Kliethermes M. Developing a clinical practice. Ambulatory Care Pharmacy

Preparatory Review and Recertification Course; 2014.• Gupta V, Williams E. Establishing a New Ambulatory Care Practice Site as a Pharmacy

Practice Faculty. Pharmacy (Basel). 2018;6(4):111. • Castelli G, ed. ACCP Ambulatory Care Pharmacist's Survival Guide. American College

of Clinical Pharmacy. 4th ed; 2019.

• Largest issue is the lack of guidance on billing strategies.

Service Workflow Example

Integrated Comprehensive Medication Management visit

PharmD

• Initiates visit by taking med history, patients medication experience and beliefs

• Assesses for indication, efficacy, safety and adherence

• Identifies med therapy problems

PCP

• Joins visit

• PharmD presents gathered history

• MD performs additional assessments

PharmD, PCP +Patient

• Develop an action plan with input from all parties

PharmD

• Enters any agreed upon med orders or related labs

• Provides patient education

• Establishes pharmacy home and ensures access/affordability

Follow-up: phone, pharmacist visits, additional integrated visits

Jurga T. Great Lakes Pharmacy Resident Conference. Purdue University. April 2018.

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Billing Codes Available for Pharmacists

• Chronic Care Management• 99487, 99489, 99490

• Transition Care Management• 99495, 99496

• Evaluation / Management• 99211 – 99215

• Annual Wellness Visit• G0438, G0439

• Diabetes Self-Management Training• G0108, G0109

• Facility Fee• G0463

Identifying Key Players

• Safety

• Risk Management – “Institutions systems, processes, and reports implemented to detect, monitor, assess, mitigate, and prevent risks”

• Therapeutics – committee which assess clinical services provided by the institution to ensure quality of care provided

Identifying Key Players

• Billing / Compliance

• Ensure billing processes are consistent with rules and regulations set forth by federal and state law, CMS, and private payers

• Coders specialized in utilizing correct code, and bill for clinical services

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Challenge: Billing Structure

• Identify & pursue codes which will be charged for service rendered

• Often the first step if charging for pharmacist direct patient care is new to your institution

• Codes utilized have associated requirements which can impact the workflow of your service• Documentation• Supervision• Frequency

• Balance & address requirements pertaining to:• Workflow• Quality / patient outcomes• Revenue potential

• Ex: established need to develop a system-wide Coumadin clinic• Question of supervision (i.e. safety) &

requirements to charge

Challenge: Changing Climate

• COVID-19• Mid-March, had began to see increase clinic volume which abruptly declined• Nearly all patient care transitioned to remote monitoring

• Previously identified need to establish billing for phone encounters• Had not yet established which billing code to utilize• COVID-19 led to pursuit of video visits d/t CMS relaxation on telehealth

• Limited utility• Patient population: unable to conduct VV or unwilling to schedule• Workflow: scheduling video visit w/o certainty of when INR will be available

Challenge: Optimization

• Establish telephone billing• Majority of time spent engaging patients through the phone

• Time spent, but not capturing revenue

• Evaluation & Management• Level I for all encounters, despite ability to bill beyond level I

• Currently in question again d/t recent change in stance by CMS

• Forces service to be volume based in order to optimize ROI

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Challenge: Aligning Vision & Goals

• Pharmacy Department• Expand ambulatory services• Generate revenue

• Department of Internal Medicine• Reduce physician burden• Maintain / improve clinical outcomes

• Key Players• Abide by CMS rule & regulation• Ensure safety

Solutions

• Communicate directly with key players

• Service model proposals summarizes:• Clinical operations

• Policies & procedures

• Identify what pharmacist billing structure is allowed• If not already allowed, establish at your institution through education

Solutions

• SWOT analysis• Does the current billing structure allow goals to be met?

• If not, propose revision to a structure better suited to meeting goals or to allow for appropriate expansion/scaling of service

• Document allocation of time• Help identify how to optimize or new potential billable services

• Find/become a Champion

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Assessment # 1

Which of the following roles best represent pharmacist services in the ambulatory care setting?

A. Inpatient order verification

B. Medication therapy management

C. Aminoglycoside dose adjustment

D. Medication procurement and dispensing

Assessment # 2

Billing & compliance officers are primarily concerned with which of the following?

A. Processes to prevent risk

B. Following regulation of payers

C. Quality of clinical service

D. Use of correct billing codes

Assessment # 3

Which of the following provides a summary of clinical operations, policies & procedures intended to guide your clinic?

A. Service model proposal

B. SWOT analysis

C. Billing Structure

D. CMS rule & regulation

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References

1. Helling DK, Johnson SG. Defining and Advancing Ambulatory Care Pharmacy Practice: It Is Time to Lengthen Our Stride. ASHP Ambulatory Care Conference and Summit. 2014

2. American College of Clinical Pharmacy. accp.com/careers/boardFAQ.aspx. Accessed July 16, 2020.

3. Jurga T, Rockstad M, Loafman M. Evaluating the Impact of Clinically Integrated Medication Management by Pharmacists for High Risk Patients with Uncontrolled Type 2 Diabetes in a Primary Care Medical Home. Great Lakes Pharmacy Resident Conference. Purdue University. April 2018.

4. CPT Code Overview and Code Approval. Available at: https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval. Accessed June 28, 2020.

5. What is Risk Management in Healthcare? Available at: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197. Accessed on June 28, 2020.

6. Smith, MR. FAQ: Pharmacist billing using “incident-to” rules non-facility (physician-based) ambulatory clinic. ASHP Amb Care Practitioners, 2019.

7. CMS, Evaluation & Management Services. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243514 Accessed on June 28, 2020.

8. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Available at: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf Accessed June 28, 2020

9. Dietrich E, Gums J. Incident-to billing for pharmacists. J Manag Care Spec Pharm. 2018;24(12):1273-76

10. Kliethermes M. Developing a clinical practice. Ambulatory Care Pharmacy Preparatory Review and Recertification Course; 2014.