Statement of the Problem of Billing System Program

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Statement of the Problem of Billing System Program Powered By Docstoc
					        Software,
     Documentation,
       and Billing

Daniel E. Buffington, PharmD, MBA
                 Director
   Clinical Pharmacology Services, Inc.

   Jaime Hendrickson, PharmD
       Manager of MTM Services
       SUPERVALU Pharmacies
                Financial Disclosures
Daniel Buffington, PharmD, MBA, Clinical Pharmacology
Services, Inc.
declares no conflicts of interest or financial interests in any product or service mentioned
in this program, including grants, employment, gifts, stock holdings, or honoraria.

Jaime Hendrickson, PharmD, SUPERVALU Pharmacies
declares no conflicts of interest or financial interests in any product or service mentioned
in this program, including grants, employment, gifts, stock holdings, or honoraria.
            Learning Objectives
•   Explain how documentation systems can be used
    to track patient care and analyze outcomes
•   Describe features of software systems that allow
    for documentation and billing of MTM services
•   Explain how consistency in documentation and
    billing requirements could benefit development and
    delivery of MTM services
•   Discuss aspects of an efficient billing system for a
    community pharmacy, including the use of billing
    codes
Medication Therapy Management:
  Evolving Practice Mechanics

   Daniel E. Buffington, PharmD, MBA
     Scope of Pharmacist Services




 Patient    Drug Regimen     Problem       Physical    Adherence       Disease     Medication
Education      Review      Intervention   Assessment   Persistence   Management   Management



Minimal focus                                                            Multi-focused
Triage-minded                                                        Multi-relationship
Short-term nature                                                   Chronic in nature
Instantaneous                                                           Accountability
                                                           Drug/Patient/Disease Model
MTM Impact in Pharmacy Practice
                           Community



             Outpatient   Office/Clinic


                          Home Health


                            Hospital

  Pharmacy   Inpatient
                           Institutional


                             Skilled
                             Nursing

             Long Term      Adult
                          Congregate
               Care         Living

                          Rehabilitation
Features of Available Web Platforms
                 Medication
             Therapy Management


             Drug Regimen Review



              Patient Education




                Prescriptions
Documenting MTM Services
   Jaime Hendrickson, PharmD
      Documenting Patient Care

• Comprehensive documentation needed for:
  – Quality and continuity of care
  – Evaluation of outcomes
  – Back-up to billing
• Documentation procedures guide standardization
  of service delivery
Minimum Documentation Components
 • Patient demographics (name, DOB, etc.)
 • Allergies
 • Medical conditions
 • Medication list
 • Problems identified
 • Pharmacist’s plan/recommendations
 • Prescriber response, if applicable
      Tracking Patient Outcomes
• Third-party payers
  – Patient satisfaction
  – Utilization (general Rx, generics)
  – Impact of pharmacist intervention on health
    care costs
• Pharmacy providers
  –   Patient satisfaction
  –   Objective parameters
  –   Achievement of goals of therapy
  –   Status of drug therapy problems
  –   Estimates of impact on health care costs
    Documenting Patient Care
• Existing methods of documentation
  – Paper charts
  – Electronic documentation systems
     • Web-accessible documentation systems
     • Integrated patient care documentation software
                  Paper Charts
    Pros                       Cons
•   Easy implementation      • Cumbersome to
•   Fit into most settings     maintain
•   Low cost                 • Risk of omission of
                               important data with
                               free-hand
                               documentation
                             • Tracking and reporting
                               patient outcomes is
                               very challenging
       Features of Electronic
      Documentation Systems
• Electronic patient record/chart
• Single pharmacist interface
• Web accessible in many cases
• Programmable to require documentation of certain
  data elements
• Able to pull billing elements out of documentation
  to meet payer requirements
• Wide variety of reports can be generated (patient,
  billing, outcomes)
      Limitations of Electronic
      Documentation Systems
• Set-up/licensing fees often apply
• Training required
• Pharmacist may need access to computer at
  point-of-care
• May not be integrated with pharmacy
  computer system
               Web Platforms
• Identify payers, simplify contracting
• Minimize variability for pharmacist providers when
  working with many payers
• Patient identification/referral mechanism
• Allow access to patients’ information, pharmacy
  claims data, and formulary information
• May allow for customization
• Simplification of documentation/billing
   Limitations of Web Platforms

• Only able to document and bill services to the
  plan sponsors using that platform
• Limited fields for documentation; may not serve
  as a comprehensive data source
• Variability of documentation systems/procedures
  still exist between payers
Billing Methods for MTM Services

• Web platforms bundle documentation/billing
• Other electronic documentation systems
  may interface with payer electronically
• Pharmacy computer system (NCPDP 5.1)
• Paper billing
  – Fax
  – Mail
• Other
         With All of These Options,
          What Should I Choose?
• What fits best in your existing
  environment/organization?
   –   Hardware
   –   Software
   –   Web accessibility
   –   Other patient care programs requiring documentation
• What payer opportunities exist for your
  pharmacy?
   – Payers may require use of certain systems, limiting
     your ability to choose
                Strategy
• Choose a documentation method that
  works best for you
• Ensure documentation includes data to
  satisfy any payer documentation and billing
  requirements
• Interface with payers to the extent
  necessary for billing
   Pharmacist Services
Technical Advisory Coalition
         (PSTAC)
Billing
          CPT Codes:
Medication Therapy Management
               Medication Therapy Management Service(s) (MTMS)
               describe face-to-face patient assessment and intervention
               as appropriate, by a pharmacist. MTMS is provided to
               optimize the response to medications or to manage
Category III
               treatment-related medication interactions or complications.

               MTMS includes the following documented elements: review
               of the pertinent patient history, medication profile
               (prescription and nonprescription), and recommendations
               for improving health outcomes and treatment compliance.
               These codes are not to be used to describe the provision of
               product-specific information at the point of dispensing or
               any other routine dispensing-related activities.
          CPT Codes:
Medication Therapy Management
 0115T    Medication therapy management service; initial
          assessment or intervention, individual, face to face
          with the patient, each 15 minutes

 0116T    Reassessment or intervention, individual, face to
          face with the patient, each 15 minutes

+ 0117T   Each additional 15 minutes (List separately in
          addition to the code for the primary service—use
          0117T in conjunction with 0115T and 0116T)
J Am Pharm Assoc. 2007;47:491-5.
          What MTM ―Is Not‖

• Not ―dispensing-related‖ services
• Not provision of ―medication leaflet‖
• Not ―physician service‖
• Not ―ambulatory care‖ testing supplies
          Current Challenges
• Practitioner mentality
• Payer acceptance
• Realistic payment rates
• Increase volume of service
• Improve documentation
• Standardize billing documentation
• Delineation of pharmacist vs pharmacy
• Practice model development
Diversity of Payer Types
Health Care Industry Standard       Current MTM Payer Market




         CMS 1500               Diverse Quantity and Specificity of Data


       Standardized                     Non-Standardized
      Minimum Dataset            ―Attempting to Capture Outcomes‖
Minimum Documentation Components
 • Patient demographics (name, DOB, etc.)
 • Allergies
 • Medical conditions
 • Medication list
 • Problems identified
 • Pharmacist’s plan/recommendations
 • Prescriber response, if applicable
Event / Transaction
                      Clinical Practice Documentation




                                                                    Outcomes
                          Service       Electronic Medical Record
                             or               Data Collection
                         Procedure          Quality Assurance
                                          Disease Management
Questions & Answers
     Self-Assessment Questions (JH)
1.   Which of the following statements is true?
      a.   All MTM payers have the same requirements for
           documentation of services
      b.   All MTM providers must use the same documentation
           method
      c.   All MTM services are billed the same way
      d.   None of the above

2.   What is the most important component of a
     documentation system for pharmacist services?
      a.   Collects data necessary for billing
      b.   Guides standardization
      c.   Integrates into existing pharmacy environment
      d.   All of the above
     Self-Assessment Questions (DB)
1.   CMS pays pharmacists to perform MTM services for
     Medicare Part D beneficiaries.
      a.   True
      b.   False

2.   The CMS 1500 form captures all of the following data
     points, except:
      a.   Patient name
      b.   Date of service
      c.   Statement of outcome
      d.   Service codes
  Self-Assessment Questions (DB)

3. Which organization is representing pharmacists on the
    American Medical Association’s Current Procedural
    Terminology (CPT) Editorial Panel ?
     a.   Pharmacist Services Technical Advisory Coalition (PSTAC)
     b.   Centers for Medicare and Medicaid Services (CMS)
     c.   National Association of Boards of Pharmacy (NABP)

				
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Description: Statement of the Problem of Billing System Program document sample