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Journey Beyond Dispensing: Exploring Clinical Services

in Community Pharmacy

Amina Abubakar, PharmD, AAHIVP

Olivia Bentley, PharmD, CFts, AAHIVP

Southeaster Leadership Conference 2019

Introductions and Disclosures

Amina Abubakar is the pharmacist owner of Rx Clinic Pharmacy,

an independent pharmacy in Charlotte, NC and Olivia Bentley is

the Director of Collaborative Care Services

They have nothing to disclose

Objectives

Pharmacists

Discover different opportunities to implement clinical services in community pharmacy and in collaboration for a physician or medical provider

Obtain new code updates for Remote Patient Monitoring, Chronic Care Management and more

Learn how to convey the value of a pharmacist to medical provider to initiate a collaboration relationship

Pharmacy Technicians

Discover different opportunities to implement clinical services in community pharmacy and in collaboration for a physician or medical provider

Understanding the value and importance of interprofessional collaboration in the pharmacy setting

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Why Clinical Services?

Giant Timber Bamboo

Our Journey in Building Clinical Services

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Practice Sites: Rx Clinic #1

Independent Community Pharmacy with Enhanced Clinical Services

Medication Synchronization 100%

URAC Accredited Specialty Pharmacy

AADE Accredited Diabetes Education Program

Enhanced Community Services: Integrated MTMs using Clinical Technicians

Point-of-Care Testing

Pharmacogenetic Program

Travel Health and Immunization Services

Insulin Pump Training

Durable Medical Equipment Supplier

Diabetic Shoes

Non-sterile Compounding

Practice Sites:Rx Clinic #2

Independent Medical Practice with In-house Pharmacy

Clinical Pharmacist embedded in a medical practice Annual Wellness Visit Chronic Care Management Transitions of Care Management Smoking Cessation Weight Loss (IBT for Obesity) IBT for Cardiovascular Disease Travel health medicine & immunizations

(Yellow Fever Certified) Pharmacogenetic Testing Pharmacist-led Acute Care Clinic Team-based Care

Other Practice Sites

Community-Am Care Hybrid Clinical Pharmacist

Part-time Staffing

Part-time at different medical practices

Primary Care Medical Clinics

12 total practices in the Charlotte and greater area

Assisted Living Facilities

Federally Qualified Health Center (FQHC)

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Clinical Services

(Anything Beyond Dispensing)Pharmacist

Billed

Core Pharmacy Services

MTM / CMR

Immunizations

Routine

Travel health

eCarePlans

Advanced Pharmacy Services

Point-of-Care

Testing

Prescription Protocol (State

Specific)

Specialized Consultation

Services

BHRT

Wellness, Functional Medicine

Expert Pharmacy Services

PGxTesting

Insulin Pump

Training

Diabetes Self-

Management Education

Diabetic Shoes

Medical Nutrition Therapy

Requires addition training,

certification or accreditation

Provider Billed

Core Collaborative Services

Annual Wellness Visits

(AWV)

Add-on Services

Advance Care

Planning

IBT for CVD

Alcohol Misuse

Depression

Smoking Cessation

STI

Diabetic Foot

Cognitive Care

Planning

Initiate CCM

Chronic Care Management

(CCM)

Transition of Care

Management (TCM)

Advanced Collaborative

Services

IBT for Obesity

Continuous Glucose Monitoring

Remote Patient

Monitoring

Behavioral Health

Integration

Expert Collaborative

Services

Incident-to E/M visits

Educational CKD

Services

How to build clinical

services in community Pharmacy

“There are no barriers.

There are only detours”

Adapting Your Pharmacy Workflow For Clinical Services

Are you Med Sync’ed?

Are you maximizing your Med Sync with clinical value?

How are you capturing interventions in dispensing to bill for MTM and eventually CCM?

Does everyone in your pharmacy know how to describe upsolutionsto patients?

What is the single point of failure for your programs?

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Optimize your current staff to avoid adding additional payroll cost

Foundation• Company culture and personnel development plans• Structure of stations, efficient workflow, tasking• Initiating Medication Synchronization• Knowing essential reports to demand from your dispensing system

Optimization• Optimizing workflow and Med Sync for integration of clinical services• Training staff to have a clinical mining mindset• Leveraging your technicians• Impactful and profitable MTM

Innovation• Pharmacist-driven clinical services in community pharmacy• Integrating CCM into your pharmacy workflow• Actions that bring value to quality measure for medical providers

Clinical Mining Opportunities

Clinical Mining

occurs in dispensing

Enhanced Services Care

Team

Pharmacist performs clinically

necessary duties

Coordination of Care

What Clinical Services Should I Start First?

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Clinical Services

(Anything Beyond Dispensing)Pharmacist

Billed

Core Pharmacy Services

MTM / CMR

Immunizations

Routine

Travel health

eCarePlans

Advanced Pharmacy Services

Point-of-Care

Testing

Prescription Protocol (State

Specific)

Specialized Consultation

Services

BHRT

Wellness, Functional Medicine

Expert Pharmacy Services

PGxTesting

Insulin Pump

Training

Diabetes Self-

Management Education

Diabetic Shoes

Medical Nutrition Therapy

Requires addition training,

certification or accreditation

Provider Billed

Core Collaborative Services

Annual Wellness Visits

(AWV)

Add-on Services

Advance Care

Planning

IBT for CVD

Alcohol Misuse

Depression

Smoking Cessation

STI

Diabetic Foot

Cognitive Care

Planning

Initiate CCM

Chronic Care Management

(CCM)

Transition of Care

Management (TCM)

Advanced Collaborative

Services

IBT for Obesity

Continuous Glucose Monitoring

Remote Patient

Monitoring

Behavioral Health

Integration

Expert Collaborative

Services

Incident-to E/M visits

Educational CKD

Services

What’s your low hanging fruit?

Top 10 Tips for Clinical Services in

Community Pharmacy1. Dispensing must be performed fast, efficient and safe

2. Make sure your have the right people on the bus and in the right seat

3. Med Sync vs. Clinical Med Sync

4. Maximizing Clinical Technicians

5. Optimize your Med Sync to unlock time to develop clinical services

6. Become a one-stop shop Travel Health Center

7. Use eCare Plans to bring value for the work you do

8. Run reports to determine your provider mix, payer mix and disease mix in your pharmacy to tailor your services

9. Education, certification, accreditation STRATEGICALLY

10. Share your value from interventions with medical providers

Key Clinical Services that can be

Performed in Community Pharmacy through Collaboration

Chronic Care Management, Transitions of Care Management, and

Behavioral Health Integration

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Why Collaborate?

Primary Care Providers & Pharmacists have a lot in common

Unmaximized potential

Practice at the top of our license

Receives offers to sell out to chains or hospital systems

Measured: Star ratings, MACRA/MIPS/APM

Increased workload with low reimbursements

Preferred networks

Chronic Care Management

Monitoring, implementing, modifying a patient’s care plan for

their chronic disease states

Monthly codes used by a qualified healthcare profession (QHP)

to bill for non-face-to-face time spent on chronic care

management

Eligibility: Medicare beneficiary must have at least 2 chronic

conditions (12 months or lifetime)

General Supervision = may be performed anywhere

Copays and deductible DO apply unless patient has secondary

coverage or is duel eligible

Chronic Care Management

CY 2018 Codes

99490 – Non-complex CCM, 20 mins (2019 PFS $38.41-44.17)

99487 – Complex CCM, 60 mins (2019 PFS $84.11-$96.73)

99489 – Additional Complex CCM, +30 mins (2019 PFS $42.06-$48.37)

99491 – CCM provided personally by a physician or QHP

PFS $76.97-$88.52

At least 30 mins of professional time per calendar month

Meant to account for time that the billing practitioner is doing the care coordination work that is attributed to clinical staff in 99490

What about FQHC/RHC?

99491 is included in the rate setting for FQHC/RHC General Care Management Code G0511. However, note that G0511 rate will increase to $67 for 2019.

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Chronic Care Management (CCM): Billing

Codes that Cannot be Billed During the Same Month as a Chronic Care Management

Transition Care Management (CPT 99495-99496) Unless TCM ends earlier in the service period

CCM should not billed during the 30-day TCM period

Home Healthcare Supervision (HCPCS G0181)

Hospice Care Supervision (HCPCS G0182)

Certain ESRD services (CPT 90951-90970)

Patient Monitoring Services (CPT 99090 and 99091) Often bundled with other services

Note: If time such as a phone call, leads to an office visit resulting in an E&M charge, that time would be included in the billed office visit, NOT the CCM time.

Requirements Performed with general supervision Comprehensive Care Plan Only contract time counts Certified CCM Technology: Access to Care: Ensure 24/7 Clinic

AccessMust have patient’s written consent

(no longer a 2017 requirement) Must have verbal consent documented

Chronic Care Management (CCM): Care Plan DocumentationFive Basic Requirements for EACH Disease State

1. Needs Assessment (medical, functional, and psychosocial)2. Preventative care services◦ List what and when services are due◦ E.g. Immunizations, routine labs, routine procedures3. Medication reconciliation◦ Efficacy, adherence, ADR, DDI◦ Patient education including goals and expectations of therapy4. Self-management Checklist (monitoring, diet, exercise, etc)5. Goals and follow up plan for each disease state

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The Care Team

Qualified Health Professionals (QHP)

• Physicians (see exception)

• Physician Assistant• Nurse Practitioner• Clinical Nurse Specialist• Certified Nurse Midwife

Clinical Staff

• Any practitioner that can be billed incident-to

• Personnel that works under the supervision of the QHP

• Advanced practice registered nurses, registered nurses, licensed specialist clinical social workers, licensed practical nurses, pharmacists, certified medical assistants

Non-clinical Staff

• Any personnel who are not clinical staff or QHPs

• Time cannot be counted toward the CCM time requirement

• Can facilitate the service delivery to maximize the pharmacist’s time with the patient

• e.g. receptionist, pharmacy support staff that books appointments, relays CCM service information (Per APhA example)

Chronic Care Management (CCM): Billing

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Code Payment (PFS non-facility)

Clinical Staff Time Care Planning Documentation

Billing Practitioner Responsibility

Non-Complex CCM (99490)

$43 20 minutes Established, implemented, revised or monitored

Ongoing oversight, direction and management

Complex CCM (99487)

$94 60 minutes Established or substantially revised

Ongoing oversight, direction and management + Medical Decision-making of mod-high complexity

Complex CCM Add-on (99489)

$47 Additional 30 minutes

Established or substantially revised

Ongoing oversight, direction and management + Medical Decision-making of mod-high complexity

Initiation of CCM during a visit

$64 N/A Established Personally performs extensive assessment and CCM care planning beyond usual effort for the separately billable initiating visit

Determining Medical Decision Making (MDM)

https://emuniversity.com/MedicalDecision‐Making.html

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• Straightforward

• Low Complexity

• Moderate Complexity• High Complexity

Four levels of MDM

• Nature and number of clinical problems

• Amount and complexity of data reviewed by clinician

• Risk of morbidity and mortality to the patient

Level of Complexity is based on:

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Chronic Care Management (CCM): Settings

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Community Pharmacy

With EHR Access

WithOUT EHR Access (Care Plans)

Pharmacist Embedded in the Clinic

Primary Care

Outpatient/ Ambulatory 

Care

Assisted Living

Independent Living

Skilled Nursing 

Exceptions

Federally Qualified Health Center (FQHC)

Non‐complex CCM ONLY

Jan 1, 2018 New Code

Transitions of Care Management

Occurs in the outpatient/primary care setting

General Supervision 

Medication reconciliation 2‐business days after discharge is essential to billing TCM

Code Description Non‐Facility Price

99495 Moderate medical decision making performed 

within 14 days of discharge

$161

99496 High medical decision making performed within 

7 days of discharge

$228

Behavioral Health Integration (BHI)

Purpose: improve health outcomes for patients with mental or behavioral health conditions

CPT Code: 99484 General BHI for 20 mins or more of clinical staff time per calendar month

General supervision under a QHP

ICD-10 codes: MANY; eligible if patient has at least 1 behavioral health or psychiatric condition being treated by the provider, including substance use disorders, that in the treating provider’s clinical judgement, warrants BHI services.

2018 PFS: non-facility $48.60, facility-based $32.76

Copays and deductibles DO apply

Must have has an initiating visit no more than one year prior to receiving BHI

E/M excluding 99211

IPPE

AWV

Patient consent must be documented verbal or written either during or after an initiating visit

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Exciting Changes for 2019

Conversion factor increased from $35.99 to $36.04

Reducing documentation policies for E&M visits in 2019-2020

Advanced changes to documentation, coding and payment to E&M visits implemented in 2021

Two new physician furnished services using communication technology (Virtual check-in and Remote evaluation of recorded video and/or images from an established patient)

Expansion of telehealth for treatment of opioid use disorder and other substance use disorders

Adding Prolonged preventative services codes to Telehealth (G0513 and G0514)

New FQHC/RHC Virtual Communication Service code (G0071) for communication technology-based services and remote evaluation of services

Three new codes and requirements for Remote Patient Monitoring

One new code for Chronic Care Management

Interprofessional Internet Consultation codes: 99446-99449 for physician to physician

CMS Payment for Remote Communication Technology

G2012 – Virtual Check-in

• Purpose: reduce unnecessary office visits

• Must be performed by the QHP that furnish E/M services in REAL TIME

• Established patients only

• Not related to an E/M service within the previous 7 days or next 24 hours

• 5-10 minutes of medical discussion

• Audio-only real time allowed

• PFS 2019: $13.50 - $15.53

• Copay/Ded DO APPLY

• Verbal Consent Documented

• CMS noted this could be used as part of a treatment regiment for opioid use disorders and other SUD to assess whether an office visit is needed

CMS Payment for Remote Communication Technology

G2010 –Remote Eval of Pre-recorded Video/Images

• Purpose: reduce unnecessary office visits

• Must be performed by the QHP that furnish E/M services

• Established patients only

• Not related to an E/M service within the previous 7 days or next 24 hours

• Includes review of video and brief communication within 24 hours (via phone, audio/visual, text, email or patient portal)

• PFS 2019: $11.50 - $13.23

• Copay/Ded DO APPLY

• Verbal Consent Documented

• *Main difference is that this is pre-recorded data with a 24 hours response time and the previous code was real-time

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Federally Qualified Health Centers (FQHC)

and Rural Health Centers (RHC)

Remote Communication Technology billing allowed under PFS

(instead of PPS)

At least 5 minutes of Virtual Check-in or Remote Eval of

Recorded Services are furnished by an RHC/FQHC practitioner

to a patient seen within the previous year

Virtual Check-in Code: G0071 (NEW)

Remote Evaluation of Recorded Services: G2010 (SAME)

Copay/ded still applies

Chronic Care Remote Physiologic

Monitoring (RPM)

99091 did not accurately describe service covered and three new codes were created using updated RVU

Remote monitoring of physiologic parameter(s), e.g. weight, blood pressure, pulse oximetry, respiratory flow rate

99453 (PFS $17.13-$19.70) – Initial set-up and patient education

99454 (PFS $56.66-$65.16) – Initial device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days

99457 (PFS $46.70-$53.71) – CCRPM treatment management services, 20 minutes or more of clinical staff/physician/QHP time in calendar month requiring interactive communication with patient/caregiver

Describes professional time = cannot be furnished by auxiliary personnel incident-to a practitioner’s professional service

Clinical Staff are either employees OR working under contract to the billing practitioner

Chronic Care Remote Physiologic

Monitoring (RPM) FAQs

What type of technology qualifies?

Many have asked CMS but CMS did not offer any specifics in the final rule

Examples include: software application integrated with a smartphone, Holter-monitors, Fitbits, artificial intelligence messaging, behavioral health data, data from wellness applications, results of a patient’s self-care tasks

Does RPM require face-to-face exam or interactive audio-video?

No, services do not require use of interactive audio-video

New patients or patient not seen by the practitioners within one year prior to billing RPM, the practitioner must furnish a face-to-face visit with patient

Is there a patient copay?

Yes, patient is responsible for 20% unless they have secondary coverage or are duel eligible

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Chronic Care Remote Physiologic

Monitoring (RPM)

FAQs

Can RPM also be billed with Chronic Care Management?

Yes, a provider can bill both 99457 and 99490. However, time spent furnishing these

services cannot be counted towards the required time for both RPM and CCM codes for

a single month (i.e. no double counting). Accordingly, billing both requires at least 40

minutes total (20 minutes of CCM and 20 minutes of RPM).

Can the 99454 codes used for setting up the device initially be billed monthly?

This code can be billed every 30 days and cover the device supply with daily

recording(s) or programmed transmission alerts each 30 days

Chronic Care Remote Physiologic

Monitoring (RPM) FAQs

Who can deliver CCRPM services?

CPT 99457 (20 mins of service) performed by physician, QHPs, or clinical staff

Examples of clinical staff: RNs, medical assistants or any person working under the

supervision of a physician or QHP AND who is allowed by law, regulation and facility to

perform or assist in the performance of a specified professional service, but who does not

individually report that professional service

Can CPT Code 99457 be billed “Incident-to”?

99457 describes only professional time and “therefore cannot be furnished by auxiliary

personnel incident-to a practitioner’s professional services.”

This position is in stark contrast to CMS’s current stance on CMS whether services are billed

incident-to under general supervision. It also appears contradictory to the descriptor itself.

Where do pharmacists fit in the new

regulations for RPM?

CMS Definitions

Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician

CPT defines a clinical staff member as "a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service; but who does not individually report that professional service."

According to AAFP submitted questions for clarification to CMS. CMS will publish an update.

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The Real Value of Pharmacist-led Clinical Services

Rx Clinic Pharmacy Outcomes

“Through this residency, I learned how to develop

programs that are geared towards taking better care

of our patients.”

“As a recent graduate who is just starting in my pharmacy career, I know that I can achieve each and

every one of my professional goals as a member of this team.”

“[Amina and Olivia] keep pushing the needle so that we can continue

to stay relevant in today's ever-changing healthcare industry.”

“I chose this residency for the team, but I stayed for the mission to create jobs for pharmacists across the

country.”

“By all accounts, [Mandy] continues to provide care beyond my expectation from a pharmacist and she’s doing it well.”

- Richard Wynn, MD

“[The clinical pharmacists] have been instrumental in helping me provide more comprehensive care.”

- Wesley Thompson, MHS, PA-C, AAHIVS, DFAAPA

“[Jessica] demonstrated a very high level of clinical knowledge and communication skills in working with staff and patients from a diverse background. We were delighted to work with her and know that she

can look forward to an excellent career as a clinical pharmacist.”- Dr. Clarence Ellis, MD

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Save a Pharmacist, Save a Family.

Questions?

For additional questions and contact information, please email

our administrative assistant rahma@avantinstitute.com