Billing Boot Camp for the Pharmacist

Billing Boot Camp for the Pharmacist Presenter: Rosalind Chorak, BSPharm, NCPS

Prepared by: Mark Tetteh-Ocloo and Jessica Calles, Doctor of pharmacy Candidates 2018

Learning Objectives  Evaluate the current healthcare environment and the increase in billing opportunities it allows for Pharmacists.  Explain the basics of healthcare billing and the current opportunities for generating revenue for pharmacists’ patient care services.  Describe the Evaluation and Management key components and regulatory requirements to bill for pharmacist services using E&M codes.  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.

Disclosure Statement

Rosalind Chorak and the CareOne Team declare no conflict of interest, real or apparent, and no financial interests in any company, product or services mentioned in this program, including grants, employment, gifts, stock holdings and honoraria.

Exploring the Current Healthcare Environment 

Prevalence of chronic illness



Increasing healthcare cost



Increasing desire for better healthcare outcomes



Changing from Fee-for-service payment model to value-based care

NextGen Healthcare(2015)The definitive guide to value-based care

Prevalence of Chronic Diseases 

Increasing population with chronic diseases such as obesity, heart disease and diabetes



Aging population of baby boomers



Estimated that by 2050, 88.5 million will be aged 65 or older



8 in 10 seniors will have chronic disease

NextGen Healthcare(2015)The definitive guide to value-based care

Increasing Healthcare Cost Chronic diseases increasing healthcare cost at an alarming rate:  Heart Disease & Stroke

$432 billion per year

 Diabetes

$174 billion per year

 Lung Disease

$154 billion per year

 Alzheimer's Disease

$ 148 billion per year

NextGen Healthcare(2015)The definitive guide to value-based care

Desire to Improve Outcomes According to 2014 Healthcare costs: 

Each ER visit cost $2100



There were 136 million ER visits in 2014



Annual cost in Trillions of dollars



Current drive of stakeholders is to reduce avoidable ER visits, hospitalizations and readmissions by improving outcomes

NextGen Healthcare(2015)The definitive guide to value-based care

Fee-for-Service to Value Based Care 

Current fee-for-service model no longer sustainable



Outcomes and cost containment will drive incomes



To help transition from fee-for-service to value-based care, congress created 3 programs to link payment to value/quality: • • •

Meaningful Use EHR Incentive Program (MU) Physician Quality Reporting System (PQRS) Physician Value-Based Payment Modifier (VBM)

NextGen Healthcare(2015)The definitive guide to value-based care

Meaningful use of EHR (MU) 

A program which offers incentives to providers who adopt certified electronic health record technology (CEHRT)



Also exacts penalty on providers who do not comply with the CEHRT



Penalty impact payments 2 years later

NextGen Healthcare(2015)The definitive guide to value-based care

Physician Quality Reporting System (PQRS) 

Uses a combination of incentives payments and adjustments to promote specific quality measure tracking and reporting



Quality measures released yearly



Physicians are required to report 9 quality measures annually.



Attracts incentives for compliance and Penalties for non-compliance



Penalty impacts payment after 2 years

NextGen Healthcare(2015)The definitive guide to value-based care

Valued Based Payment Modifier (VBM) 

Newest value-based payment method based on the PQRS program



Creates two groups of eligible providers: •

PQRS compliant providers subject to quality tiering system based on performance relative to their peers

•

PQRS non-compliant providers have additional penalty phased in by year based on practice size

NextGen Healthcare(2015)The definitive guide to value-based care

The Carrot-and-Stick Payment Approach 

CMS offers front-end incentives for participating medicare physician compliance in MU and PQRS



CMS also exacts penalty for non-compliance with MU and PQRS requirements after a 2-year lag period, adding up to 4.5 %



What you did or did not do in MU or PQRS directly impacts your payment after 2 years



MU and PQRS requirements started in 2013, VBM went into effect in 2015

NextGen Healthcare(2015)The definitive guide to value-based care

Impact on Provider Income Performance year

Payment year

MU Penalty

PQRS Penalty

VBM Penalty

Total Penalties

2013

2015

1-2%

1.5%

1%

3.5-4.5%

2014

2016

2%

2%

2%

6%

2015

2017

3%

2%

4%

9%

2016

2018

3-4%

2%

TBD by CMS

TBD by CMS

NextGen Healthcare(2015)The definitive guide to value-based care

CMS Goals for Value-based Care  Improve clinical quality  Address misuse of services  Deliver patient centered care  Improve patient safety  Avoid unnecessary costs

NextGen Healthcare(2015)The definitive guide to value-based care

 Reengineer care processes and system-wide workflows  Make performance result transparent  Reduce existing care disparities

Vale-based payment model Associated with improving patient outcome and reducing cost of care delivery The term “value-based” also means the following:  Pay for performance (P4P)

 Value-based purchasing

 Risk sharing

 Risk adjusted care

 Incentivized payments

 Population based payments

 Capitation arrangements

 Gain sharing

NextGen Healthcare(2015)The definitive guide to value-based care

Opportunities for All Healthcare Providers  To meet MU,PQRS, and VBM requirements, insurance companies and Medicare participating practices are willing to contract services to care providers including pharmacists

 Available opportunities include:  Chronic care management (CCM)

 Annual wellness visits (AWV)

 Transitional Care Management (TCM)

 Medication Therapy Management (MTM)

 Diabetes Self management Training (DSMT)

 Population Health Management

NextGen Healthcare(2015)The definitive guide to value-based care

Checkpoint ď ľ

The key drivers of incomes in the current Healthcare system are: A. Fee-for-service and better outcomes B. Fee- for-service and cost containment C. Cost containment and better outcomes D. Fee-for-service and risk sharing

Checkpoint ď ľ

The key drivers of incomes in the current Healthcare system are: A. Fee-for-service and better outcomes B. Fee- for-service and cost containment C. Cost containment and better outcomes D. Fee-for-service and risk sharing

Basics of Healthcare Billing 

Medical Billing Terminology



Examples of E&M Codes



Pharmacist CPT Codes



Incident-to Physician Referral



Fee-for-services versus Fee-for-Value



Fee-for-service models for pharmacist

Medical Billing Terminology 

Evaluation and Management Code (E/M) 





Current Procedural Terminology Code (CPT) 

Describes health care related procedures performed in addition to E/M services



Set by the American Medical Association

International Classification of Disease Ninth Revision Code (ICD-9) 



Describes services such as hospital visits, office visits, and consultations

Used to describe disease states when submitting charges

National Provider Number (NPI) 

A unique number designated to a provider that is used when submitting charges to a third party

Stump , A. (2006) Billing for pharmacy services in ambulatory care . ACCP Ambulatory Care New Practitioner Survival Guide/ Resource Manual.

E&M Codes Code

Complexity of decision making

Level of History Obtained

Length of visit (minutes)

99211

Minimal

Minimal

5

99212

Straightforward

Problem focused

10

99213

Low complexity

Expanded problem focused

15

99214

Moderate complexity

Detailed

25

99215

High Complexity

Comprehensive

40

Stump , A. (2006) Billing for pharmacy services in ambulatory care . ACCP Ambulatory Care New Practitioner Survival Guide/ Resource Manual.

Pharmacist CPT Codes 

Charge is based on the amount of time providing the service to the patient



Charges are submitted to a third party payer for payment 

A contract is negotiated with each insurance payer

CPT Code

Type of visit

Length of visit (minutes)

99605

Initial patient visit

15

99606

Subsequent patient visit

15

99607

Additional time during initial or subsequent visit

Additional 15

Incident-to Physician Referral 

This billing practice uses E&M and ICD-9 codes to bill and describe the complexity of the visit.



Submitting charges is based on two of the following three components:





Amount of patient history reviewed for patient visit



The complexity of decision making



Physical examinations performed

Patients must have an established relationship with the physician before being referred to the pharmacist.

Fee-for-Service Versus Fee-for-Value 

Fee-for-Service •

Each service performed is associated with a fee

•

Reimbursed for quantity of services rather than quality

•



Fee includes time spent with the patient and costs of any laboratory services provided

Fee-for-Value •

Reimbursement is dependant on achieving patient specific health outcomes

•

Promotes quality versus quantity

Stump , A. (2006) Billing for pharmacy services in ambulatory care . ACCP Ambulatory Care New Practitioner Survival Guide/ Resource Manual.

Fee-for-Service Models for Pharmacists 

Annual Wellness Visit (AWV)



Medication Therapy Management (MTM)



Transitional Care Management (TCM)



Diabetes Self-Management Training (DSMT)



Chronic Care Management (CCM)

Annual Wellness Visit (AWV) 

A preventable service offered to medicare beneficiaries once a year



May be completed by a physician or another healthcare provider under the direct supervision of a physician



Must be a medicare beneficiary for more than 12 months



Concerns addressed in the visit include: •

Review of current health conditions

•

Review of family history

•

Assessing height, weight, and blood pressure

•

Assessing risk factors

CMS. (2017) The ABCs of the Annual Wellness Visit (AWV). Medicare Learning Network.

Transitional Care Management (TCM)  Help ensure patients are adequately transitioned from an inpatient hospital setting to and outpatient community setting  Must be delivered within 30 days of being discharged  Consists of 3 components: 

Initial patient contact within 2 days of discharge



Non-face-to-face clinical services such as:



•

Medication reconciliation

•

Review of discharge documents

•

Order labs for patient appointment

A face-to-face consultation with the patient •

Typically about 30 minutes in length

Bonner, L. (2017)Medicare services position pharmacists in new revenue generating models. http://pharmacytoday.org/article/S1042-0991(17)30078-6/pdf.

Diabetes Self-Management Training (DSMT) 

Patient education on self-management of diabetes



DSMT program requirements:



•

Must be accredited by ADA or AADE

•

Must have a collaborative agreement with a provider that can bill for services

To be enrolled in service the patient must: •

Have a written referral to the program

•

Have a diabetes diagnosis

Kliethermes, M. Leal, S. Sachdev, G. (2016) Billing Boot Camp. APhA 2016 Annual Meeting & Exposition.

Get paid for Chronic Care Management 

Providers may bill under the 2015 Medicare Physician Fee Schedule



Bill up to $42 per patient per month for CCM



About $4000 per month for every qualified 100 patients



An opportunity to be reimbursed for services already being provided for chronically ill patients

NextGen Healthcare(2015)The definitive guide to value-based care

Chronic Care Management (CCM) 

Must have two or more chronic conditions



At least 20 minutes of clinical time provided in chronic care management



May be non-face-to-face clinical time



Pharmacist may provide this service in collaboration with a physician 



Use incident-to physician billing for pharmacy services

A comprehensive care plan must be created and revised

CMS. (2016) Chronic Care Management Services. Medicare Learning Network.

Checkpoint What billing code describes services such as hospital visits, office visits, and consultations?

A.

Current Procedural Terminology Code (CPT)

B.

Evaluation and Management Code (E/M)

C.

International Classification of Disease Ninth Revision Code(ICD-9)

Checkpoint What billing code describes services such as hospital visits, office visits, and consultations?

A.

Current Procedural Terminology Code (CPT)

B.

Evaluation and Management Code (E/M)

C.

International Classification of Disease Ninth Revision Code (ICD-9)

Checkpoint Which fee-for-service model is a preventable service offered to medicare beneficiaries once a year and typically includes a review of current health conditions, family history, and risk factors?

A.

Chronic Care Management (CCM)

B.

Diabetes Self-Management Training (DSMT)

C.

Annual Wellness Visit (AWV)

D.

Transitional Care Management (TCM)

Checkpoint Which fee-for-service model is a preventable service offered to medicare beneficiaries once a year and typically includes a review of current health conditions, family history, and risk factors?

A.

Chronic Care Management (CCM)

B.

Diabetes Self-Management Training (DSMT)

C.

Annual Wellness Visit (AWV)

D.

Transitional Care Management (TCM)

Kennedy Center Pilot Study 

Scope: To develop and evaluate collaborative sustainable business model(s) for pharmacist provided Comprehension Medication Management (CMM) within a PCMH



Focus: Patients with diabetes, lipid disorders, hypertension, congestive heart failure, obesity and multiple/complex therapies



Duration: November 1, 2013 - October 31, 2014 (~1yr)



Funding: BCBS SC MTM and KPIC pharmacists

Davis B.(2015) Billing for pharmacist collaborative patient care services. SCSHP 2015 annual meeting

Outcome Measures



Quality: improvement in A1C, LDL, and BP



Physician productivity



Revenue: return on investment



Cost avoidance

Typical Interventions 

Medication reconciliations



Allergy identified, clarified or prevented



Lab/test evaluation, patient consultation or recommendation



Medication change of dose adjustment



Patient counselling-self care



Adverse effects identified/remedied

Practice Agreement Pharmacists Interventions in the study were based on: Collaborative practice agreements  Pharmacists scope of practice  Treatment algorithms 

A1C Improvement Results 84% of patients with an A1c >10 showed improvement

77.2 % of patients with an A1c > 7 showed improvement

LDL Improvement Results 86.2% of patients with an LDL-C >130 showed improvement

79.1% of patients with an LDL-C >80 showed improvement

Blood Pressure Improvement Results 72.4 % of patients with a SBP >140 showed improvement

81.3% of patients with a DBP >90 showed improvement

Physician Productivity Results Data revealed that physician productivity increased by 20.6%

Return on Investment New Expenses

$140,000

Value-Annualized • Revenue (FFS& P4P) • Physician productivity • Cost avoidance/quality • Customer satisfaction

$98000 $220,000 $1,756,000 Priceless

Davis B.(2015) Billing for pharmacist collaborative patient care services. SCSHP 2015 annual meeting

Cost Avoidance Results Month

Encounters

Interventions

$ Avoidance

Avoid/ Encounter

April

205

909

$139,260

$679.32

May

197

969

$148,379

$753.19

June

200

990

$151,531

$757.66

Choosing the Right Model 



Understand your patient population o

Who they are

o

Who you will be measured against

Establish your baseline population o



Understand your population risk and opportunities

Determine measurement targets o

What will you be measured against

NextGen Healthcare(2015)The definitive guide to value-based care

Choosing the Right Model ď ľ

ď ľ

Institute cash flow and interim payments o

Assess reimbursement models

o

Assess how payments will be disseminated to provider groups

Define care coordination capabilities o o

How are your providers integrated How do you coordinate or provide care management capabilities NextGen Healthcare(2015)The definitive guide to value-based care

Designing a Practice Model  



Conduct an environmental scan and SWOT analysis focusing on need Conduct a gap and feasibility analysis • What are the gaps in care • What are the services available to fill the gaps • Where is the service located Consider financial opportunities • Increase number of patients achieving therapeutic goals • Increase revenue potential of physicians • Increase revenue potential of clinic • Increase access to patient care Kliethermes, M. Leal, S. Sachdev, G. (2016) Billing Boot Camp. APhA 2016 Annual Meeting & Exposition

Designing a Practice Model Consider the interest of stakeholders- send out feelers  Develop a business plan  Implement the service • Billing • Legal • Operations • Policy and procedures  Measure outcome 

Kliethermes, M. Leal, S. Sachdev, G. (2016) Billing Boot Camp. APhA 2016 Annual Meeting & Exposition

Example of a Collaborative Practice Agreement

Collaborative Practice Agreement Scope of Practice

Collaborative Practice Agreement Services Provided by Pharmacists

Collaborative Practice Agreement Treatment Guidelines

Conclusion 

The desire for better outcome and cost control will drive healthcare delivery going forward



The fee-for-service payment model is giving way to value-based care



To meet quality and outcome requirements, insurance companies and Medicare provider practices are open to contracting healthcare services



New and experienced pharmacists have opportunities to work on contract and bill under physician codes



Pharmacists also have opportunity to leverage their skills and services to design collaborative practice models that provide value in new payment models

References       

Stump , A. (2006) Billing for pharmacy services in ambulatory care . ACCP Ambulatory Care New Practitioner Survival Guide/ Resource Manual.

Davis B.(2015) Billing for pharmacist collaborative patient care services. SCSHP 2015 annual meeting Bonner, L. (2017)Medicare services position pharmacists in new revenue generating models. http://pharmacytoday.org/article/S1042-0991(17)30078-6/pdf.

CMS. (2016) Chronic Care Management Services. Medicare Learning Network.

CMS. (2017) The ABCs of the Annual Wellness Visit (AWV). Medicare Learning Network.

Kliethermes, M. Leal, S. Sachdev, G. (2016) Billing Boot Camp. APhA 2016 Annual Meeting & Exposition.

NEXTGEN Healthcare (2015)The definitive guide to value-based care. https://bridge.nextgen.com/media/3241/nextgen-healthcare-ebook-value-basedrevenue-edu51.pdf