The Practice of Pharmacy's Future: Provider Status

Andrew Hibbard PharmD, BCACP, BCGP Zachary Rosko PharmD, BCPS, CDE The Practice of Pharmacy’s Future: Provider Status United States Public Health Service USPHS Report to the US Surgeon General 2011

“One of the most evidence-based decisions to improve the health system is to maximize the expertise and scope of the pharmacist and minimize expansion barriers of an already existing and successful health care delivery model.”

Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011. Pharmacist State Provider Status Bills 2019

• In 2019’s Legislative session: • 147 state provider status bills for pharmacist • 39 states had bill introduced • 22 bills in 18 states where signed into law as of 06/10/2019

• National Alliance of State Pharmacy Associations Provider Status Bill Categories: • Scope of practice bills • Designation of pharmacist’s as providers • Payment for pharmacist-provided patient care services

Provider Status: State Level

• Domain one: • Provider designation • Is there language that identifies pharmacists as providers in state code?

• Domain two: • Scope of practice should align with education and training that pharmacists receive today • Examples: Post-diagnostic disease state management, medication therapy management, prescriptive authority, diagnostic authority, state-wide protocols..ect

• Domain three: • Reimbursement for cognitive services • Payment should not be attached to the product being dispensed • Payment should be a covered health service • Payment for the service should not solely be put on the consumer/member • Payment should not be limited by place of service (POS) with some exceptions

Providing clinical services that are compensated with in a fee-for-service Pharmacist Provider construct Status = Credentialed network provider within a health plans major medical benefit

Prescriptive Authority “Scope Creep” Pharmacist Provider Dispensing Dependent Status ≠ Payment Extra Training or Certification

The Oregon Trail

careoregon.org

CareOregon is…

Founded in 1993, CareOregon is a nonprofit, community benefit company serving over 300,000 Medicaid and Medicare members. Our mission is building individual well-being and community health through shared learning and innovation. Our vision is healthy communities for all individuals, regardless of income or social circumstances.

careoregon.org

The Pharmacist Collaborative: Mission & History

• Established to encourage peer-to-peer support & identify best practices for clinic pharmacists “Medication trauma is medication • Core group: Old Town Clinic, OHSU Richmond, complexity and lack of coordination that Legacy Emanuel/Good Sam, Multnomah Co., overwhelms the patient, caregivers and Virginia Garcia providers resources creating fear, • First meeting Mar 2012 & continues to meet confusion, error which leads to poor monthly adherence, compliance and outcomes.”

Jim Slater, Pharm.D. • Funded a pilot grant for clinical pharmacy services VP of Pharmacy Jan –Dec 2013 CareOregon • Goal: provide clinical pharmacy services to high acuity patients in order to ensure effective drug therapy management.

• Focus on contracting & credentialing for pharmacist 2012 fee-for-service (FFS) billing 20152018

careoregon.org

Clinic Pharmacy Partners • LOA with 5 clinics: • Central City Concern • Legacy • MCHD • OHSU Richmond • Virginia Garcia • Embedded pharmacists: • Clackamas County Health Dept. • Neighborhood Health Center

careoregon.org 2015

Where We Started

• 2015: Clinic Embedded Pharmacist Pilot • 1 Full Time Clinical Pharmacist • 1 Part Time PGY2 Ambulatory Care Pharmacy Resident • 1 Part Time PGY1 Managed Care Pharmacy Resident

Funded by the health plan and embedded in an existing Federally Qualified Health Center with a large density of complex health plan members.

Goals: Clinical Pharmacists to meet 1 on 1 with members and perform medication reviews to coordinate medication use. Determine if billing for clinical services can sustain integrated clinical pharmacy. Objectives: -Track change in DTCR Score -Track change in RX spend per member/year. -Collect 50% of pharmacist salary in reimbursement for billed encounters.

careoregon.org Medical Documentation Basics Medical Documentation Basics: Background

• Medical documentation and record keeping is integral to good professional practice and the delivery of health care Documentation Tips • Electronic or paper records Always Document What You did and Why You Did It! • Enables continuity of care and enhance communication across healthcare professionals Documentation Tips • Clinical records should be updated by all members of the patients care team If you did not write it down, it did including pharmacists not happen.

• Continuity in clinical notes is of vital importance to patient care! Documentation Tips

Every entry should be timed, • A structured way to record your interactions with your patients dated, and signed

• Include any clinically substantive discussions related to the patients new or existing problems or routine care Documentation Tips Thorough, accurate, objective, • “The duty to share information can be as important as the duty to protect professional, factual, and legible patient confidentiality” Caldicott NHS to all readers

Medical Documentation Basics

• Clinical Notes Should Include Poor Clinical Records • Patient demographics • Misinform healthcare professionals, and • Reason for current visit patients • Scope of examination • Increase medical legal risks and liability • Waste health care resources • Positive exam findings • Jeopardize patient care • Pertinent negative exam findings • Lead to serious incidents • Key abnormal test findings • Reduce revenue gained • Diagnosis or impression • Increase revenue lost • Can have significant legal implications • Clear management plan and agreed actions

• Treatment details and future recommendations • Medications administered, prescribed, renewed • Drug allergies • Instruction to the patient (oral & written) • Clinical justification • Recommended follow up date

Medical Documentation Basics: Overview

• Common Progress Note Formats • Subjective, Objective, Assessment, and Plan • Subjective, Objective, Assessment, and Recommendation • Subjective, Objective, Assessment, Plan, and Recommendation • Situation, Background, Assessment, and Recommendation

• A structured way to record your interactions with your patients • Include any clinically substantive discussions related to the patients new or existing problems or routine care

• There potential for many readers of a patient’s chart including: • Other providers • Insurance Claims Administrators • State board peer reviews • Attorneys • The patient

• Progress notes should: • Be clear and succinct • Readable and transparent devoid of jargon and obscure abbreviations • Your clinical reasoning should be explicit to the naivest readers

SOAP Note

S - Subjective Data: • Descriptive information that is unsupported by diagnostic tests or procedures • Generally obtained from the patient O - Objective Data: • Physical examination, labs, procedures, imaging studies A - Assessment: • What the practitioner thinks the patients problems are • Based on subjective and objective data P - Plan: • Ordering of medications, labs, procedures, imaging

SOAP Note

S - Subjective: • Chief complaint (cc) • History of Presenting Illness (HPI) • Past medical history (PMH) • Family History (FH) • Social (SH) • Medications • Allergies • Review of Systems (ROS)

History of Present Illness (HPI) PPQRSSTA • Precipitating (What caused the condition?) • Setting – what the patient was doing when the symptoms occurred

• Palliative factors (What has provided relief?) • Things that make the symptoms better or worse

• Quality (Describe the condition) • Specific descriptive terms of symptoms (sharp pain, black tarry stools)

• Radiation (Is it localized? Where else does it occur?) • Usually used when assessing pain

History of Present Illness (HPI) PPQRSSTA • Site/Severity (Where is the problem? How severe is it?) • Location – precise area of symptoms • Mild, moderate, severe

• Temporal factors (When did the problem begin? How often does it occur?) • Timing - Onset, duration, frequency of symptoms

• Associated symptoms/ROS (Are there any other symptoms?) • Ask ROS questions that relate to the organ system(s) and problem associated with the chief complaint Application

“What is the best medicine you have out here for headaches?” CC: Headache for the last 2 hours HPI John is a 35 yo financial analyst at a local hospital. He has had a headache for the last 2 hours and would like to take an OTC for relief. He took 325mg of APAP 1/2 hour ago with no relief PMH Exercise induced asthma GERD SH Lifetime non-smoker, Coffee: ~1/2 pot/day (none today, late for work) Medications Albuterol MDI prn Prilosec OTC 20mg qam APAP 325mg PRN Drug Allergies/ADR Penicillin (hives) Codeine (nausea) ROS Throbbing behind eyes, Gets headache rarely

SOAP Note

O - Objective Pearl Do not put new orders in the objective • Vital signs section unless they have been resulted • Physical Exam Findings already • Reported or reviewed lab Results • Imaging results • Procedures • Risk Factors • Other diagnostic data • Recognition and review of documentation of other clinicians SOAP Note

SOAP Note

A - Assessment • Diagnosis or differential diagnosis • Reasons for assessment • Conditions progression and status • Improving, worsening, maintaining improvement, acuity patterns • Medication compliance and tolerability • Problem (listed in order of importance) • Should justify treatment plan

• The synthesis of “subjective” and “objective” provides evidence to justify what you are going to do, and why your seeing the patient today SOAP Note

S - Subjective Data: • Descriptive information that is unsupported by diagnostic tests or procedures • Generally obtained from the patient O - Objective Data: • Physical examination, labs, procedures, imaging studies A - Assessment: • What the practitioner thinks the patient's problems are • Based on subjective and objective data P - Plan: • Ordering of medications, labs, procedures, imaging

SOAP Note P - Plan • What testing is needed and rationale for choosing the test • What next steps would be if results are positive or negative • Therapy needed (Orders): medications, labs, imaging, procedures • Referral to specialist(s) or additional provider(s) for consult • Patient education, counseling • Status/agreement of treatment plan progression

• The content under S_O_A_P headings should be consistent. It is appropriate move the headings around to streamline communication.

Medical Documentation Basics: Summary

Information provided by the patient. Tracking the course of the condition(s) you are treating. Changes in condition. Response to treatment. New symptoms. Condition effects on daily living. Compliance to treatment plan. Medications.

Anything you observe or test in office during that visit demonstrating the medical necessity for treatment you rendered. General appearance, Demeanor, Physical Findings, Laboratory Findings, Outcome Measurements.

Your reasoning for doing what you are doing. Identify the problems your managing (diagnosis). Indicate condition progression or status such as improving, worsening, maintaining improvement, acuity patterns. Your S and O must support your assessment.

The treatment rendered during your visit or plan to render after the visit. Todays treatment. Patient education and instruction. Future care plans or referrals. Notes indicating test results. Goals and Outcomes. When the patient is returning. Patient instructions Show Me Charting Patient Case #1: HG

2020 Case Recordings - Hermione Granger Review of Chart

Physician’s Office Visit Note 9/2/19 Our Note (With EMR)

Our Note (Without EMR) Patient Case #2: NL

2020 Case Recordings - Neville Longbottom Practice Breakout Session Documenting Break Documentation Debrief Keep your note for later!!!

Our Note (With EMR)

Introduction to E&M Evaluation and Management Services

• General definition: • Coding set used to document the provision of health care services (evaluation and/or management of health concern or problem) by physicians or other qualified healthcare professionals. • Definitions established by AMA and published in the CPT coding manual. • Identifies: • Patient Type • Setting of Service • Level of E/M Service Provided (Preventative or Problem Based; Level of Complexity) • Purpose: • Establish a standard definition and weighting of the expenses (practice, work and malpractice) of delivering health care services • Used for the purposes of reimbursement

Setting of Service

Our Focus Today Other Settings • Office or other outpatient • Hospital Inpatient settings (Ex: FQHC, Medical • Hospital Observation Office, Pharmacy) • Emergency Department

• Nursing Facility • Code Set 99201 - 99215 • Assisted Living Facility • Home Care • Telephonic/Telemedicine

Patient Type New or Established?

Level of Evaluation and Management

• E/M services recognize seven components used in defining the level of E/M services • History • Examination Key components • Medical decision making • Counseling • Coordination of care Contributory factors • Nature of presenting problem • Time Proxy for total work done before, during, and after the visit Office and Outpatient E&M Levels: New Patient

• New patient requires all 3 key components (CPT: 99201-05):

• “A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same specialty or subspecialty who belongs to the same group practice, within the last 3 years.”

• Nurse practitioner (NP), or physician assistant (PA) working with physicians within the same practice = same specialty/subspecialty

• Pharmacist working with physicians, NP, PA of the same practice AND specialty= same specialty/subspecialty • Ex: Primary Care Pharmacist (BCPS or BCACP) is the same specialty as MD PCP. • Ex: Clinical Pharmacy Specialist – Psychiatric Service (BCPP) is = PMHNP.

AMA CPT Coding Manual Quick Reference 99201-99205

Office and Outpatient E&M Levels: Established Patient • Established patient requires 2/3 key components (CPT: 99211-15)

• “Patients who have received any professional service from a physician or other qualified healthcare practitioner of the same specialty/subspecialty within the last 3 years.”

• Probably the most relevant for pharmacist providing post diagnostic disease state management and working under a collaborative practice agreement

AMA CPT Coding Manual Quick Reference 99211-99215 Components #1 and #2 History and Exam Components #1 and #2 History and Exam Category and Extent of History Obtained (S)

• Problem focused • Chief complaint; brief h/o present illness or problem • Expanded problem focused • Chief complaint; brief h/o present illness; problem pertinent system review • Detailed • Chief complaint; extended h/o present illness; problem pertinent system review extended to include review of a limited number of additional systems; pertinent past, family, and/or social history directly related to patient’s problems • Comprehensive • Chief complaint; extended h/o present illness; review of systems that is directly related to problem(s) identified in the HPI plus a review of all additional body systems; complete past, family, and social history Three Domains of History (S)

Category Components Type of History CC HPI ROS PFSH Problem Focused Required Brief N/A N/A Expanded Problem Required Brief Problem Pertinent N/A Focuses Extent Detailed Required Extended Extended Pertinent Comprehensive Required Extended Complete Complete

• Highly subjective and does not need to be in the correct order • Stick with a style and documentation standard you are comfortable with and align the components to the service • Not all the patient’s history needs to be documented within every encounter • Perfectly acceptable to review ROS and PFSH from an earlier encounter and update only pertinent differences to limit amount of re-documentation History of Present Illness (HPI) • Location: “Chest Pain”, sore “knee”

• Severity: Statement of degree of measurement regarding “how bad it is”, “improved status”, or “Fasting BS is 200”, or “can't sleep”

• Timing: When or at what frequency. “constant”, “morning”, “5 minutes in duration”

• Associated signs and symptoms: Any associated or secondary complaints related to the problem

• Modifying factor: Anything that makes the problem better or worse “medications”, “when standing”

• Context: What patient was doing, environmental factors/circumstances surrounding the compliant “while sleeping”, “slipped and fell”

• Duration: When did the complaint occur, duration of diagnosis “2 weeks ago”, “in childhood”

• Quality: Any characteristic about the problem and/or expresses an attribute “dull” ache, “sharp” pain, “metallic” taste Review of System (ROS)

• Series of question seeking to spot signs and symptoms that the patient may be experiencing or has experienced

• Can be made by clinician or support staff

• Can be verbal or filled out by the patient (patient intake forms)

• Should help dictate the need for further physical examination, testing, or the possible affected medicines

• Review maybe about the system(s) directly related to the problem(s) identified in the HPI and additional system(s) that could be impacted Review of System Cont. (ROS)

• Commonly misconceived as associated sign and symptoms • Can only get credit for 1 domain either HPI or ROS • Must be medically necessary • Example HPI No double “Patient states that their knee has been painful. dipping. Denies any other MS complaint”.

ROS Past, Family, and Social History (PFSH)

• Past History: Past experiences with illness, operations, injury, treatments, and medications • Family History: Review of medical events in patient’s family, age at death, diseases, hereditary conditions that put the patient at risk • Social History: Age appropriate review of past and current activities Smoking status, ETOH use, sexual activity, martial status, ect • Don’t use “non-contributory” • Instead use “Reviewed and no changes” or update as appropriate

Putting it all Together (S) • All three areas of history must line up with a level of service, or default to the lowest of the three Components #1 and #2 History and Exam Physical Examination (O)

• Problem focused • Limited exam of the affected body area or organ system • Expanded problem focused • Limited exam of the affected body area or organ system and other symptomatic or related organ system(s) • Detailed • Extended exam of the affected body area(s) and other symptomatic or related organ system(s) • Comprehensive • General multisystem exam or a complete exam of a single organ system Use the 1995 or 1997 E/M Guidelines

• Rule of thumb always perform a problem focused exam or expanded problem focused exam

Level of exam Perform and Document Problem focused One to five elements identified by a bullet Expanded At least six elements identified by bullet problem focus Detailed At least two elements identified by a bullet from each six areas/systems OR At least twelve elements identified by a bullet in two or more areas/systems Comprehensive Perform all elements by a bullet in at least nine organ systems or body areas and documents at least two elements identified by a bullet from each of nine areas/systems System/Body Area Elements of Exam

Constitutional • Measurement of 3 out of 7 of the following: 1) Standing BP; Obtain for all 2) Supine BP; 3) Pulse rate and regularity;4) respiration; 5) patients Temperature; 6) height; 7) Weight • General appearance of patient

Eyes • Inspection of conjunctivae and lids • Examination of pupils and irises • Ophthalmoscopic examination of optic discs and posterior segments Ear, Nose, Mouth, • External inspection of ears and nose Throat • Otoscopic examination of auditory canals and tympanic membranes • Assessment of hearing • Inspection of lips, teeth, gums • Inspection of nasal mucosa, septum, turbinate's • Examination of oropharynx: oral mucosa, Salivary glands, hard and soft palate, tongue, tonsils, pharynx System/Body Area Elements of Exam

Neck • Examination of neck (symmetry, masses, appearance) • Examination of thyroid (enlargement, tenderness, mass) Respiratory • Assessment of respiratory effort (use of accessory muscles) • Percussion of chest (dullness, flatness, hyperresonance) • Palpation of chest (tactile fremitus) • Auscultation of lungs (breath sounds, rubs) Cardiovascular • Palpation of heart (location, size, thrills) • Auscultation of heart (murmurs, abnormal sounds) • Carotid arteries (pulse, amplitude, bruits) • Abdominal aorta (size, bruits) • Femoral arteries (pulse amplitude, bruits) • Pedal Pulses (pulse amplitude) • Extremities for edema and varicosities Chest • Inspection of breast (symmetry, nipple discharge) • Palpation of breast and axillae (masses, lumps, tenderness) System/Body Area Elements of Exam

Gastrointestinal • Examination of abdomen (masses or tenderness) • Examination of lever and spleen • Examination for presence or absence of hernia • Examination of anus (hemorrhoids, rectal masses) • Obtain stool sample for occult blood test Genitourinary • Examination of scrotal contents • Examination of penis • Digital rectal examination of prostate gland • Pelvic examination • Examination of urethra • Examination of bladder • Cervix • Uterus • Adnexa/parametria Lymphatic Palpation of lymph nodes in two or more areas: Neck; Axillae; Groin; other System/Body Area Elements of Exam

Musculoskeletal • Examination of gait and station • Inspection of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, infections) • Examination of joints, bones, and muscles of one or more of the following: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; 6) left lower extremity • Inspection and assessment: misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, range of motion, pain, crepitation, or contracture, stability, dislocation, contracture, muscle strength, muscle tone, atrophy, or abnormal movements Skin • Inspection of skin and subcutaneous tissue (rash, lesion, ulcers) • Palpation of skin and subcutaneous tissue System/Body Area Elements of Exam

Neurologic • Test cranial nerves with notation of any deficits • Examination of deep tendon reflexes with notation of pathological reflexes (Babinski) • Examination of sensation (tough, pin, vibration, proprioception) Psychiatric • Description of patient’s judgement and insight • Brief assessment of mental status including: 1) Orientation to time, place, and person. 2) Recent and remote memory. 3) Mood and affect (depression, anxiety, agitation)

• Know your boundaries and when to refer out to a diagnostic provider for a more in-depth physical assessment.

• Basic vital should be completed at all patient visits regardless if billing based on time or medical decision making Components #1 and #2 History and Exam Complexity of Medical Decision Making (AP)

Number of Diagnosis Amount and/or Risk of Type of Decision or Treatment complexity of data complications Making Options reviewed and/or M/M Minimal Minimal or none Minimal Straightforward Limited Limited Low Low complexity Multiple Moderate Moderate Moderate complexity Extensive Extensive High High complexity

• Must meet or exceed 2 of the 3 elements to qualify for the type of decision making • Appropriate to use time of visit a predictor of complexity • Multiple diagnosis (DM+HTN+DLD) + insulin should be moderate to high most of the time • Low complexity (HTN, anticoagulation, Contraception) typically are straight forward therapeutic decisions by themselves Scoring Medical Decision Making (Marshfield Clinic Scoring) Problem Points Data Points Risk Overall MDM 1 1 Minimal Straightforward Complexity 2 2 Low Low complexity 3 3 Moderate Moderate Complexity 4 4 High High Complexity

• Only 2 out of 3 elements required • Rare that review Data Points would meet high complexity when seeing established patients • Patients is quite ill or requiring immediate emergency or specialty services • Multiple uncontrolled condition • Severe exacerbation of a chronic problem • Acute illness that threatens life or bodily function Problem Points

Problems Points Scoring Example Self-limited or minor (Maximum of 2 points) 1 Established problem, stable, or improving 1 1 + 1=2 Established problem, worsening 2 2 New problem, with no additional work-up 3 planned (Maximum of 1) New problem, with additional work-up planned 4 Total 4=High complexity

New problem = New to the provider Not to be confused with definition of a new patient Data Points Data Reviewed Points Example Review or order clinical lab tests 1 1 Review or order radiology test 1 Review or order medicine test (PFTs, EKG, ect) 1 Discuss test with physician 1 Independent review of image, tracing, or 2 specimen Decision to obtain old records 1 Review and summation of old records 2 Total 1=Straightforward complexity • 1 point given for reviewing and ordering updated HbA1c, CMP, Lipids

Risk Categories (Highly Subjective) Risk level Presenting Problem Diagnostic Management procedure Options Minimal Risk • Self limiting or minor • Standard clinical • Rest, gargles, problem (Cold, insect and medicine fluid, bandages bites, Tinea Corporis) labs Low risk • 2+ Self limiting or • Physiologic test • OTC drugs minor problems not under stress • Miner surgery • 1 stable chronic illness • Non- • Physical Therapy • Acute uncomplicated Cardiovascular • Occupational injury or illness imaging studies Therapy (cystitis, allergic • Superficial • IV fluids no rhinitis) needle biopsy additives • ABG • Skin biopsies

• Any of the elements in Any of the three categories listed Risk Categories (Highly Subjective) Risk level Presenting Problem Diagnostic Management procedure Options Moderate • Two stable chronic dx • Physiologic test • Prescription Risk • One chronic illness with under stress drugs mild • Diagnostic • IV fluids w/ exacerbation/progression endoscopies additives • Acute complicated injury • CV Imaging • Nuclear medicine (fall w/ LOC) • Obtaining fluid • Elective or minor from body cavity surgery High Risk • 1+ chronic illness with • Invasive • Drug therapy moderate procedures requiring exacerbation/progression • Cardiac EP studies intensive • Acute or chronic illness that • Endoscopies monitoring imposes threat to life or • Escalate/de- bodily function escalate based on • An abrupt change in status poor prognosis • Any of the elements in any of the three categories listed Keep Medical Necessity Simple • Although a comprehensive service may be your personal art or style of practice it may not be considered necessary and billable by a majority of peers

• It is the necessity of the work NOT the volume of work that should be coded and billed

• Even when billing based on time. The 50% of the visit that was focused on counseling and coordinating care must be medically necessary for the disease state in question/referral Keep Medical Necessity Simple

High Acuity Stable or Critically ill Self Limiting Progressing Prognosis poor Low Complexity Moderate to High Highest Complexity Complexity Keep Medical Necessity Simple Using duration of follow up as guide can be helpful

Annually Non-problem 3 to 6 months follow-up Weeks to months Days to weekly Oriented Components #1 and #2 History and Exam CPT Updates Definition of Time • Inclusion of time as an explicit factor since 1992 • Used to assist in selecting the most appropriate level of service (LOS) for E/M CPT codes • Used to determine LOS when counseling and/or coordinating care has dominated the visit

• CPT 2021 definitions of time: • Time can be used whether or not counseling and/or coordination of care dominates the service

• Can used as proxy for determining the LOS of visit

• Time spent must be medically necessary and supported similarly to determining the LOS for MDM CPT New Definition of Time • In 2021 time includes the following activities: • Preparing to see patient (eg, review of tests) • Obtaining and/or reviewing separately obtained history • Performing a medically appropriate examination and/or evaluation • Counseling and educating the patient/family/caregiver • Ordering medications, tests, or procedures • Referring and communicating with other health care professionals • Documenting clinical information in the electronic health care record • Independently interpreting results (not separately reported) and communicating results to patient • Care coordination Time Based Billing • When counseling and coordination of care predominate the visit (> 50%), then time is used to determine level of E/M service.

• Electing to use time to report the level of service the medical record should document. • Length of face to face time should be documented • Medical record should describe the counseling and activities done to coordinate care

Example of 99211 Visit LOS

• Established Patient 99211 Office visit for an established patient who is performing glucose monitoring and wants to check accuracy of machine with lab blood glucose by technician who checks accuracy and function of patient machine.

Office visit for a 73-year-old female, established patient with pernicious anemia for weekly B12 injection. Example of 99212 Visit LOS

• Office visit for an established patient with hypertension who is being followed up for medication management and monitoring

• Office visit for Anticoagulation management and or warfarin adjustments Example of 99213 Visit LOS

• Office visit for a 45 year-old asthmatic patient following up disease medication management who needs a renewal on their rescue inhaler. Patient was wheezing on exam and the dose of their ICS was increased.

• Office visit with an established, controlled diabetic who HbA1c is worsening while on maximally dosed oral diabetic medications. The patient is being reevaluated for therapy intensification, re-screened for hypertension, and dyslipidemia. Example of 99214 Visit LOS

• Office visit for a 65 year old female, established patient, for review and follow-up of non-insulin dependent uncontrolled diabetes, obesity, hypertension, and heart failure. Complains of vision difficulties and admits dietary noncompliance. Patient was counseled and diabetic medication were adjusted and optimized.

• Office visit for an asthmatic patient who has missed multiple days of work due to asthma exacerbations. Patient noted having increased nocturnal awakening due to seasonal allergies. Upon exam findings suggesting acute maxillary sinusitis was noted and supervising physician notified (also could be assisted with confirmation). Asthma medication regimen was intensified (STEP UP), and montelukast was prescribed. Level 5 Office Visit (99215)

• The 99215 represents the highest level of care for established patients being seen in the office. • 99215 level of care was selected in about 9% of established office patients in 2014. • Problems are of moderate to high severity • Documentation requires two out of three of the following 1) Comprehensive History 2) Comprehensive Exam 3) High Complexity Medical Decision-Making • Or 40 minutes spent face-to-face if coding based on time • Nature of counseling and coordination of care must be clearly documented and be medically necessary

Example 99215

Patient presents for follow-up of CHF. History of significant ischemic cardiomyopathy with an ejection fraction of 30%. Hypertension well controlled on current medications, but patient noted worsening lower extremity edema for the last 2 weeks. Patient complains of severe SOB over the past 3 days. CAD stable with no chest pains. Patient is compliant with medication but has not been watching his salt intake carefully. ROS, PFSH reviewed and update. Blood pressure medication and diuretic medications were increased. Potassium supplement increase. Diet and lifestyle discussed. Follow up in 3 days for monitoring.

Example of 99215 Cont.

Patient presents for follow-up for uncontrolled diabetes, hypertension, and dyslipidemia. Patient has a history significant for CAD, and ischemic heart disease. Patient angina has been stable for over 3 years. Complains of feeling like an elephant was sitting on her chest last night. Patient HbA1c is 12%. BP: 175/102. Physical assessment revealed +4 AFIB, +3 Pitted Edema Bilaterally, and in clinic EKG was order and physician assisted with interpretation. Patient was referred to Cardiology and Sent to ER for further work-up. Break Show Me (E&M) Coding Case #1 Coding

Patent HG: Evaluation and Management of Hypertension

• Chronic Disease Management Encounter

Received any Professional Service from the physician or other QHP in group of same New or specialty within the last three years? Established? Yes No

Exact Same Specialty? New Patient

Yes No

Exact Same Subspecialty? New patient

Yes No

Established New Patient Setting of Service: - 9920x or 9921x? Scoring Key Components: History HPI - (History) HPI - (History) ROS - (History) PFSH - (History) Final Score (History) Scoring Key Components: Exam Physical Exam (Examination) Soring Key Components: Medical Decision Making A. Number of Diagnoses or Treatment Options (MDM)

1 3 3 B. Data Reviewed (MDM)

1 C. Risk (MDM) Final MDM Score… Putting it all together

99214 But Wait! What About Medical Necessity?

Medical Necessity Met Selecting LOS in EMR Selecting LOS in EMR CPT Code Association to Primary Diagnosis Code (ICD 10 Code) Notes on ICD-10 Coding

• International Classification of Disease • Submitting an ICD-10 code on a claim is NOT Diagnosing • Identifies the reason(s) for the service provided and supports medical necessity • Codes may be taken from final assessment or chief complaint • May include: • Disease or condition codes (A00-Q99 Codes) • Finding or symptom codes (R00-R99 Codes) • Injury, poisoning or external causes of morbidity (S00-Y99 Codes) • Factors that influence health status and contact with health services (Z00-Z99 Codes)

ICD-10 Code Selection

• Know your scope of practice and privileging • Has a patient been diagnosed by a provider? • Patient provided self diagnosis? • Can you confer diagnosis? • Identify drug related problems? • Assess status of disease state?

• What Codes to Include • Diagnosis being addressed (to highest level of specificity) • Ex: E11.21: T2 Diabetes w/ diabetic nephropathy vs E11 Diabetes Mellitus T2 • If diagnosis unclear or not established, the finding or symptom codes • Ex: R68.89 Flu-like Sx vs J10.19 Influenza due to Influenza A virus • DO NOT include rule out or probable diagnoses in outpatient settings • If preventative, the reason for the encounter • Ex: Z71.89 Encounter for medication review and counseling • Secondary conditions that impact treatment of presenting problem

Code Cas #2: NL Code on your own 1st: Use Our Note 2nd: Use Your Note Coding Debrief What did you get? Received any Professional Service from the New or physician or other QHP in group of same Established specialty within the last three years?

Yes No

Exact Same Specialty? New Patient 9920? Yes No

Exact Same Subspecialty? New patient

Yes No

Established New Patient HPI - (History) ROS - (History) PFSH - (History)

Final Score… (History)

• Detailed History Physical Exam (Examination) A. Number of Diagnoses or Treatment Options (MDM)

1 3 3 B. Data Reviewed (MDM)

1 C. Risk (MDM) Final MDM Score… Putting it all together: 9920?

3/3 Key Components Required for New Patients

99201 How did your documentation do? Break Documentation With Intent to Bill Documentation can make or break a practice

• Poor documentation can result in: • Leaving ‘money on the table’ • Overcoding • Undercoding • Fraud, Waste, Abuse • Malpractice Risk • Poor provider performance • Errors in care transitions • Patient harm/negative outcomes Case #1: Note 2 Case #1 – Alternate HPI Case #1 – Alternate HPI Final Score (History) Revised E&M Coding to Match Documentation

Old Documentation New Documentation

99214 99213 Business Case

99213 99214 • 20 visits per day • 20 visits per day • Medicare Rate for 99213 = • Medicare Rate for 99214 = $75.32 $110.28 • Assume 40 working weeks per • Assume 40 working weeks per year x 5 Days per week = 4000 year x 5 Days per week = 4000 v/y v/y • 4000 x $75.32 = $301,280 • 4000 x $110.28 = $441,120 Case #1: Note 3

99213! Why 99213? Why 99213?

3 Case #1: Note 4

99212 Why 99212?

1 Business Case

99212 99214 • 20 Visits per day • 20 visits per day • Medicare Rate for 99212 = • Medicare Rate for 99214 = $45.77 $110.28 • Assume 40 working weeks per • Assume 40 working weeks per year x 5 Days per week = 4000 year x 5 Days per week = 4000 v/y v/y • 4000 x $45.77 = $183,080 • 4000 x $110.28 = $441,120 Case #1: Note 5

99213! Time Based Coding and Documentation Case #1: Note 6

CC but no History or Exam Not Billable!

Only 1/3 Key Elements Documented Overcoding

When the code billed is not supported by medical necessity: CPT Billed: 99215 • Medical Necessity of Presenting Problem: • Moderate Severity • 99213-4 Overcoding Continued

When face to face time is rounded up: CPT Billed: 99214 • Documentation of Face to Face time is 23 minutes • Time for CPT codes are a range and do not permit rounding • 99213: 15 – 24 Minutes • 99214: 25 – 39 Minutes

Overcoding Continued

When the documentation does not meet the key elements of the code submitted but work does Ex: Billed 99214 • Note #4 • Documentation Supports 99212 • Work performed was 99214

Overcoding Continued

When the documentation does meet the key elements of the code submitted and incudes work not performed: CPT Billed: 99214 • Documented Comprehensive Exam • Documented full ROS

• Whether intentional (to justify higher code or to provide extra reinforcement of code billed) or unintentional (EMR, late documentation) - FRAUD Overcoding Continued

When the documentation does not meet the key elements of the code submitted and work does not: CPT Documented: 99215 • Work performed best described with 99214 • Documentation captured describes 99212 • Whether unintentional selection of 99215 or intentional - FRAUD Undercoding

Under-documenting work provided: CPT Billed: 99212 • Note #4 – Documentation meets 99212 • Work performed best described as 99214 • Medical Necessity: Moderate Risk • Could be intentional or unintentional* Undercoding Continued

Coding below the work provided and the documentation provided CPT Billed: 99212 • Note #3: 99213 per Documentation • Intentional or unintentional – still undercoding • Provider billed 99212 to keep patient’s OV Copay low

Undercoding Continued

Provider coding 99211 when > straightforward MDM has occurred Undercoding Continued

Using a ‘lower’ code to describe a ‘higher’ service: CPT Billed: 99606 • MTM CPT codes describe face to face interactions with pharmacist; review of medication history and use to identify medication or treatment related problems, recommendations for intervention. • Focus is medication use, not disease state or medical condition problem.

Finding Balance with Documentation

• Let Medical Necessity Drive Documentation • Ideal when you start coding, will become second nature with time

• Features of ideal ‘real world’ documentation: • Maximizes reimbursement of the clinical encounter • Provides a clear record of the care provided including decision making and plan • Includes pertinent clinical information • Is usable by all care team members and easily understood • Minimizes liability

• Somewhere between billing minimum and didactic SOAP notes

Workflow Shortcuts Electronic Medical Records

• Note Templates • Smart Lists and Smart Links • Smart Phrases • Smart Blocks • Preference Lists

Note Templates Note templates are Smart Phrases that are placed into a Quick Button to be used as the backbone of an encounter’s documentation. The Smart Phrase may contain Smart Text that will pull in the last values in a lab or flowsheet (ex: BMI) or a Smart Block or Smart List that allows the user to select desired information at the point of service Phone Note Template

Includes the ROS Smart Block and Smart Phrase to medication list. Collaborative Drug Therapy Management Note Template ROS Smart Block Physical Exam Smart Block Smart Phrases: Create Your Own or Share Smart List vs Smart Links

PFSH Smart List (F/U Visit) PFSH Smart Link (New Patient Visit) Personal Style and Preference

Template linked to CC vs Visit Type Old School (.SOAP Smart Phrase) Utilize Preference Lists Paper Chart Templates Silver Lining Where We Went

• 2016: Formal Establishment of Pharmacy Department at NHC • 2 Full Time Clinical Pharmacists • (1.5 Clinical FTE) • 2017: Addition of 1 Full Time Pharmacy Technician • 2018-9: Expansion to 3 Full Time Clinical Pharmacists • (2.4 Clinical FTE) • 2020: Expansion to 5 Full Time Clinical Pharmacists 2 Technicians • (4.2 Clinical FTE)

Core Primary Care Teams

Core Care Team V1 Core Care Team V2 Care Team Model Team Members FTE Care Team Model Team Members FTE CCT V1 PCP Team Lead 1 CCT V2 PCP Team Lead 1 PCP 1 PCP 2 PharmD 0.5 PharmD 0.75 BH 0.5 BH 0.75 RN 1 RN 1-1.5 RN Case Manager 0.5 RN Case Manager 1-1.5 MA 2.5 MA 4

Team Total Team Total Clinical Pharmacy Services Provided

• Comprehensive Medication Reviews • Annual Reviews • F/U Review and/or Interventions • Targeted Medication Reviews • Post Diagnostic Disease Management • Collaborative Drug Therapy Management • Independent Authority • Pharmacotherapy Consultation • Preventative Services

NHC’s Payer Mix

Payer Class Percent of Total Medicaid (CCO and FFS) 62% Commercial 10% Medicare (B or Managed 6% Medicare) Self Pay 22% 100% Pharmacist Billing of Medical Claims

Credentialing Not Eligible or Not Credentialed Medical Providers Needed • State Medicaid (FFS) • Medicare B • 3 CCO Organizations • Incident-to • 1 Managed Medicare Plan • Managed Medicare* • MTM Services • Incident-to

• 5 Commercial Payors • MTM Services* • Self Pay • E&M Services

NHC Pharmacist Visits

Clinical Pharmacist Specialist Total Encounters Schedule • 2646 patient visits/year max • 8 hour work day split into 2 4 hour • Estimate 2116 visits completed if patient care sessions fully booked • 9 sessions per week (0.9 FTE clinical care) • 7 patient visits per session of 30 • 2019 Witnessed Average/FTE = minutes 2130 completed and billed • 42 budgeted clinical work weeks encounters per year • 80% historical patient show rate NHC Claims Breakdown Simple Revenue Projection in FFS Model

• Anticipated Claims x Average Claim Revenue • Average claim Revenue $97.85 (for this example will assume E&M only) • 2116 – 2646 Visits per year • 1.0 CPS FFS Claim Revenue Estimate: $207,051 - $258,911

Real Life Payment Model

Payer FFS Wrap Capitation PFP Risk Sharing Payer 1 No No Yes No No Payer 2 Yes No Yes Yes Upside Only Payer 3 Yes Yes N/A N/A N/A Payer 4 Yes Yes N/A N/A N/A Payer 5 Yes No No No Upside Only Payer 6 Yes No No No No Payer 7 Yes Yes Some Some No Payer 8 N/A N/A N/A N/A N/A Cash Yes N/A N/A N/A N/A FINANCIALLY SUPPORTING AN ENHANCED CARE TEAM IN YOUR CLINIC

NATIONALLY, THINGS ARE CHANGING

Goals of the U.S. Department of Health and Human Services (HHS):19

• 30% of U.S. health care payments in APMs or population based payments by year 2016, and

• 50% by year 2018 Ten Models of Payment

Model Notes FFS CPT code expansion Payment for non-traditionally reimbursed codes (fee for services) FFS payment Increased FFS rate level based on quality enhancement outcomes or tiers of clinic systems/providers FFS + lump sum payments Periodic lump sums are paid for wrap around (most common) services (NCQA PCMH Cert.)

FFS + PMPM Engagement driven and often include pharmacy (per-member-per-month) services FFS + P4P Based on predetermined outcome or process (pay for performance) measures (HEDIS, STARS) FFS with risk or shared Informed by ROI analysis and can include medical saving (PMPY) and pharmacy savings

Ten Models of Payment

Model Notes FFS + PMPM + P4P Monthly care coordination and retrospective outcome based payments (6-12 months) FFS + Lump Sum + P4P No requirements for lump sum with quality metrics for P4P FFS + Lump Sum + P4P + No requirements for lump sum with quality metrics PMPY for shared savings that are risk adjusted for case mix Comprehensive Risk adjusted PMPM that covers all services and payments Ten Methods of Payment20

Capitation/Care Fee for Service Management

Total Cost of Quality Care/Risk Payments Contracting Methods of Payment Fee for Service • Traditional source of income based on service performed • Negotiated with individual payers • The ten payment models purposed • FFS plays a role in 8/10 of the models • CPT and FFS is not going away any time soon • Provide a baseline minimum payment • Used for data acquisition purposes • Outcomes • Gaps in care • Risk adjustment • Engagement visit Methods of Payment Capitation/Care Management

• Per member per month (PMPM) payment for attributed members • Can be for specific services (e.g.. Care Management) • Global payment for primary care

• Supports non-encounterable interaction • Allows flexibility in the model (depending on criteria in Benefits contract) • Decreases administrative hassle and allows ability to align • Supports team based care model

• Relies on team based care model Drawbacks • Need payer penetration to make viable Quality Methods of Payment Payment

• Bonuses for meeting incentive metrics: • Incentive Measures • Medicare Stars Measures • HEDIS Measures • NCQA PCMH

• Allows additional revenue for demonstrating process and outcome Benefits metrics • With focus and priority, are achievable

• Less predictable Drawbacks • Measures and payments vary across payers Total Cost of Methods of Payment Care/Risk Contracting • Shares financial risk of care delivery • Calculates projected cost for a population • Negotiates upside and downside shared risk for achieving the target budget

• Allows maximal flexibility as long as outcomes are achieved Benefits • Supports development of deeper population management capability

• Requires infrastructure and financial support to taking risk Drawbacks • Need relationship with hospital and specialty partners to maximize effectiveness APM Example

PCMH Potential Revenue Streams

Total Qualifying Encounters 15,000 Total FFS Revenue $1,500,000 PMPM Case Rate $250/month Penetration 2016 30% Adjusted PMPM Revenue $375,000 P4P Metrics Met 6 of 15 Weighted P4P Revenue $875,000/$2,200,000 County Level Capitation Rate (wrap rate) $284 Eligible PPS Encounters 8,000 Wrap Revenue $1,472,000 Total Revenue (FFS+PMPM+P4P+Wrap) $4,222,000 CareOregon’s Clinical Pharmacy Network

CareOregon Credentialed Pharmacists 2014-2019 120

100

60 108 40 89

PHARMACISTS 67 20 42 20 0 2 2014 2015 2016 2017 2018 2019 YEAR

Total Count

2019 Year Over Medical Claims Submissions

9000

8000 7705

7000 6122

6006 5975 6000

5000

4000

MEDICAL MEDICAL CLAIMS 3000

2000

1000 706 43 0 2014 2015 2016 2017 2018 Jan - Oct 2019 YEAR Distribution CPT Categories 2014-2016

7000 6309 6000

5000

4000

3000 MEDICAL MEDICAL CLAIMS 2000

1000 4 170 178 5 89 0 Drugs Evaluation & Labs/Screenings MTM Preventative Vaccinations Management Medicine CPT CODE GROUPINGS Distribution CPT Categories 2017-2018

12000

10000 9659

8000

6000

MEDICAL MEDICAL CLAIMS 4000 2549 2000 1015 382 156 66 0 Drugs Evaluation & Labs/Screenings MTM Preventative Vaccinations Management Medicine CPT CODE GROUPINGS Distribution CPT Categories 2019

3000 2635 2500 2184

2000

1500

MEDICAL MEDICAL CLAIMS 1000 825

500 220 71 40 0 Drugs Evaluation & Labs/Screenings MTM Preventative Vaccinations Management Medicine CPT CODE GROUPINGS Sustainability is Questions? Possible