Jan Carmichael, Pharm.D., FCCP, BCPS Sharon Castle, Pharm.D., BCPS Lori Golterman, Pharm.D.

1. Coding as a Mechanism to Evaluate & Track Clinical Productivity and Workload: Are You Doing It Right? Jan Carmichael, Pharm.D., FCCP, BCPS Sharon Castle, Pharm.D., BCPS Lori Golterman, Pharm.D.

2. Coding and Billing Group • Lori Golterman, Pharm. D., VACO • Rita Brueckner, Tucson CMOP • Jan Carmicheal, Reno, NV • Sharon Castle, Charleston, SC • Keri Justice, Bay Pines, FL • Adelaide Quansah, VACO PRE • Lynn Sanders, VACO PRE • Additional Support • Lydia Borysiuk, VA New England, Connecticut • Elizabeth Stanberry, Houston, TX

3. Group Mission Background: VHA Healthcare System is a Model in the U.S. for Clinical Pharmacy Practice • Evaluate the mechanisms used by VA stations to code and bill these services • Establish a ‘best practice’ model for clinical pharmacy workload entry and retrieval • Assist the field to adopt that model • Consider future needs of pharmacy practice e.g. CMS provider status, billing and collection for clinical services

4. Learning Objectives • Review the “Hot Topics” for Coding and Billing Clinical Pharmacy Services • Demonstrate and give examples of a preferred method to code clinical workload • Select person-class & DSS stop codes to build clinics and enter workload with MTM & International Classification of Disease (ICD-9) codes in the Patient Care Encounter (PCE) tracking system • Discuss national tracking and feedback of recorded data

5. Hot Topics • New Medication Therapy Management Services (MTMS) Current Procedure Terminology (CPT) codes • Pharmacist as Provider • Person-Class Codes • Pharmacist as Independend Provider of Care • Scope of Practice • DSS Clinic Stop Codes (10 vs. 20 position) • Methods of Capturing Data • Patient Care Encounter (PCE) vs. Event Capture (EC) • Count vs. Non-Count Clinic Designation • Pharmacist as Billable Provider • CMS recognition of pharmacist on the list of billable providers • PBM to Work with Chief Business Office to Develop Billing Models

6. New National Pharmacy CPT CodesJanuary 2008 • All MTM Services Must Include: • Services provided by a pharmacist • Face-to-Face with Assessments and Interventions • 99605— • New Patient Encounter • 15 minutes in length • 99606— • Established Patient Encounter • 15 minutes in length • 99607— • Each additional 15 minutes of an initial or subsequent MTM encounter • List separately in addition to code for primary service and in conjunction with 99605 or 99606

7. Pharmacist as Provider: VA and CMS Provider Taxonomy Code Set “Person Class Codes”

8. Pharmacist as Independent Provider of Care • Scopes of Practice • Define pharmacists working independently to manage patient care • Pharmacists as Primary or Secondary Healthcare Provider • Decision Support System (DSS) Clinic Stop Codes • Primary vs. Secondary and how to define and use them • Implications

9. Decision Support System (DSS) • DSS Identifiers • Stop Codes: • VA defines production units or clinical work units (VHA Directive 2004-053 DSS Identifiers) • Pharmacy Identified by Stop Code “160” • Count vs. Non-Count Clinics • Count ≠ billable • Count ≠ face to face (may include telephone care) • Count describes a documented contact that must include a chief complaint, evaluation, and medical decision making. (VA Directive 2006-026 Pt Care Data Capture)

10. Pharmacist as a Billable Provider • CMS does not currently recognize pharmacists as a primary provider (billable provider) • Goal: To work with the Pharmacy Associations to promote Pharmacists as a Primary Provider • Goal: Work with VA Chief Business Office to pilot different billing models to third party payers

11. Methods of Capturing Data • Patient Care Encounter (PCE) vs. Event Capture (EC) • Preferred Method; PCE • Directive being drafted • Count vs. Non-Count Clinic Designation • Goal: To maximize the count clinics and capture non-count workload

12. Outpatient Encounter ExampleVisit Type Tab

13. Outpatient Encounter ExampleDiagnosis Tab

14. Outpatient Encounter ExampleProcedures Tab

15. Inpatient Encounter Example • The following slides are the steps to complete an encounter for an inpatient interaction • It is imperative that the location be changed to the appropriate location (inpatient clinic) for inpatient notes

16. Click on the location box directly next to the patient data box, found in the upper left corner of the screen. ***For INPATIENT NOTES, the location MUST be changed FIRST in order for productivity/workload to be credited to the clinic. Location block

17. Click on “Clinic Appointments” if appointment exists and select it to link the note to existing appointment.

18. If no appointment exists, click on NEW VISIT, enter name of clinic (location) and time of appointment (encounter).

19. Click on NEW NOTE, enter name of note title you wish to use. ****If there is a consult associated with visit, choose “CONSULT” title to close consult at same time note is written. With active consults, an additional dialog box will appear at bottom of Progress Note Properties box. This is the area that consults will appear, if applicable

20. Write note as you normally would.

21. Click “Action, Sign Note Now”. For NON-COUNT clinics, you will NOT be prompted for encounter data. Sign note. You MUST click encounter button after signing note. ***COUNT CLINICS: Encounter data MUST be entered before SIGNING note. Click ACTION Sign Note Now Click encounter button after note is signed

22. Click encounter button and enter encounter data as usual. Be sure to answer service connected and rated disabilities questions, visit type and/or procedure and diagnosis code to satisfy encounter. This will provide DSS with workload.

23. Example of Pharmacy DX Codes

24. Encounter data shows up below note. Encounter Data

25. NON-Count Clinics • If the clinic is non-count, you must notify DSS that you would like the clinic counted for workload. • You must check out the encounter for it to be counted for workload. • Non-count clinics will not show on the exceptions report. • The Patient Care Encounter system can be used to see if the encounter is checked out. • Variable appointment length should be designated as “YES” to allow the most flexibility in documenting workload in DSS. This allows you to schedule a patient for 2, 15 minute slots to obtain a 30 minute appointment. Scheduling in this way will allow DSS to credit 30 minutes towards workload. • DSS and the clinic set-up individual at your facility will assist you inchoosing the correct stop codes and count/non-count status. These selections will determine if the visits are billable or non-billable. • Stop codes: VHA Co-pay Directive 2007-031 • Count – Face to face visits (outpatient or inpatient)

27. Count vs NON-Count • Count Activity : • Count ≠ billable • Count ≠ face to face (may include telephone care) • Requires the corresponding progress note in CPRS includes: • chief complaint, evaluation, and medical decision making • NON-Count Activity: • Routine pharmacy activities: • screening for drug interactions, answering drug information questions, etc).

28. Examples: Count vs NON-Count Activities

29. SO WHAT? How will this help me? • Types of Reports • Workload of Inpatient and Outpatient Pharmacists • Link to ICD-9 codes • Identify station utilization for emergency relief efforts • Encounter times per patient • Population data on treatment group (patients, number of visits, readmissions, etc) • Strength of the Reports • Data Obtainable for local, VISN and national level

30. Example of Report

31. So What Can I Do? Immediate Steps for Pharmacy Chiefs: • Use New MTM Codes Now • VistA patch LEX*2*54 which was released Jan 30, 2008 (Compliance date of Feb 6, 2008) • All Direct Care Pharmacy Clinics Should be reevaluated to use Stop Code 160 in the Primary Position • Ensure Facilities Person Class Codes are Updated • Review Person Class Codes • Annually • New Employees • New Board Certifications

32. How Can We Help You? What’s Next? • Directive on the Use of PCE • Coordinated implementation of DSS and PBM Directions to the field • Conference Calls • Update CMS Pharmacy Person Class Codes in VA • Issue Paper Drafted • Request to Make Pharmacy a Primary Provider in VA • Issue Paper Drafted • IT Patch out to field …dates? What are the other patches? • Work with Chief Business Office to pilot billing models to 3rd Party Payers • Coordinate with Pharmacy Associations to promote Pharmacy to bill as a Primary Provider