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SD Pharmacy Services GuideDefinitions:General supervision: physician does not need to be on siteDirect supervision: provider needs to be on site within the office suite, but not necessarily in the same room; provider must be immediately availablePhysician-based clinic: not financially tied to a hospital, under 1 tax ID numberHospital-based clinic: financially tied to a hospitalServices allowed by practice site:Physician-based clinicHospital-based clinicFederally Qualified Health ClinicRetail pharmacyAnnual Wellness VisitXChronic Care ManagementXDiabetes Self-ManagementXXXXFacility FeeXImmunizationsXXXIncident ToXLaboratory ServicesXXXXMedication Therapy ManagementTransitions of CareXXXX***Before starting new services, send a protocol to the Board of PharmacyOther services not included in this document: insulin pump training, continuous glucose monitoring, 24-hr ambulatory BP monitoring, travel immunizations, employee based wellness programs, fee for service programsAnnual Wellness VisitFocus on required screenings and prevention planningRequirementsGeneral supervisionPatient must have already completed a Welcome to Medicare visitPatient is not within the first 12 months of Medicare Part B coverage period and has not had an initial preventative physical examination (IPPE) or annual wellness visit (AWV) within the past 12 monthsServicesInitial Annual Wellness VisitHealth risk assessment: Demographic dataSelf-assessment of health statusPsychosocial risksBehavioral risksActivities of Daily LivingInstrumental ADLsUpdate list of current providersUpdate medical/ family historyReview risk factors for depression: PHQ2, PHQ9Review functional ability and level of safety: Up and Go testAssess height, weight, BMI, and BPAssess cognitive impairment: Mini Mental Status Exam (MMSE), Minicog, Montreal Cognitive Assessment, etcScreening and prevention planningEstablish a written screening schedule for the next 5-10 years: Use United States Preventative Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) for age appropriate preventative servicesTreatment of mental health conditions or risk factorsReferral as appropriate to:Community-based lifestyle interventionsFall preventionNutritionPhysical activityTobacco use cessationWeight lossSubsequent AWVUpdate HRAUpdate list of current providersUpdate medical/ family historyAssess weight, BMI, and BPAssess cognitive impairmentScreening and prevention planningEstablish a written screening schedule for the next 5-10 years: Use United States Preventative Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) for age appropriate preventative servicesTreatment of mental health conditions or risk factorsReferral as appropriate to:Community-based lifestyle interventionsFall preventionNutritionPhysical activityTobacco use cessationWeight lossBillingCannot bill more than 1 visit per 12 calendar monthsBill under the supervising physician’s NPIAnnual wellness visit, initial visit: G0438 ($170.83)Annual wellness visit, subsequent visit: G0439 ($115.71)Business PlanCreate protocol and collaborative practice agreementDecide how much revenue goes to the provider office vs pharmacistExample: 5% staff, 15% physician group, 80% pharmacistChronic Care ManagementRequirementsGeneral supervisionPatient must have at least two chronic conditions expected to last at least 12 months or until deathChronic conditions must place the patient at significant risk of death, acute exacerbation/ decompensation, or functional declineMust have a patient-physician relationshipMust get patient consent (Cost is 20% coinsurance, pt can refuse agreement at any time)Must be able to document in an electronic health recordEnsure 24/7 access to care management services (can use patient portal)ServicesAt least 20 minutes of clinical staff time addressing 2 or more chronic conditions which place the patient at significant health riskMust documentDemographics, problems, meds, allergies, clinical summaryCare planProblem listExpected outcome and prognosisMeasurable treatment goalsSymptom managementPlanned interventionsMedication managementCommunity/ social services orders + referralsProvide the patient with a written or electronic copy of the care planBillingBill 99490 ($42.04) using CMS 1500 form using supervising physician’s NPIOnly 1 provider can be paid for the service in a calendar monthCannot bill for transitional care management, home health, hospice care, or end-stage renal disease services during the same calendar monthBusiness PlanCreate protocol and collaborative practice agreementDecide how much revenue goes to the provider office vs pharmacistExample: 5% staff, 15% physician group, 80% pharmacistDiabetes Self-ManagementRequirementsMust be a AADE or ADA accredited program (application fee $800-1100)Recognition/certification must be sent to payersProviders and pharmacies must fill out form CMS -855B to enroll as a Medicare Part B providerNeed to be a certified diabetic educator (CDE) or have similar experiencePrefer team-based careNeed physician referralServicesCovers 10 hours of initial education within a continuous 12 month period, 2 hours every year following can be coveredG0108: each 30 minutes of an individual diabetes education sessionCan use only if group visit not available within 2 months or the patient has special learning needsCan use for education after the first yearDocument individual assessments, education plan, interventions, outcomes, plan for follow-up, education time, and communication back to providerG0109: each 30 minutes of a group visitDocument ICD10 and education topics to be coveredBillingBill using the NPI of the practice (sponsoring organization) or pharmacyG0108, G0109 for Medicare patientsG0108: $52.68 reimbursementG0109: $14.16/patient reimbursementMay bill private insurance at 98960-98962 for diabetes education or may have unique codeMay pay at higher rateBusiness PlanAccredit program through ADA/AADE and send certification to payersProviders and pharmacies must fill out form CMS -855B to enroll as a Medicare Part B providerContact private insurance companies for billing codes and ratesEstablish physician referral process and documentationDetermine process for billing at different billing codes per insurance planDecide how much revenue goes to the provider office vs pharmacistExample: 5% staff, 15% physician group, 80% pharmacistFacility FeeServices performed incident to provider professional services in a hospital-based office; payment is based on a facility charge and not a professional feeRequirementsDirect supervisionPhysician-patient relationship; physician must have seen the patient before and continue to regularly see the patientService must be commonly done in practice (part of a physician’s normal bill)Must be furnished on a provider’s order (not referral- can only refer to other providers)Must be furnished in the hospital or a department of the hospitalMust have a collaborative practice agreement or protocol agreement in placeCan bill more than one facility fee from the same department, same dayServicesWide variety of services: anticoag, BP, HLD, diabetes, CHF, transplant, pain, etcDocumentation should include review of systems, laboratory data, vital signs, medication list, education provided, and time spent with the patient to justify level of billingBillingFacility fee APC 604-608 (relates to 99211-99215) on CMS 1450 (UB-04) using the physician NPI and ICD10. Will need to include an internal hospital CPT code so the billing department knows only to bill the facility fee and not the professional service fee (For example, for 99211 with modifier 17, use 9921117)Billing department will need to switch modified CPT code to APC for Form CMS 1450APC 604 (99211)APC 605 (99212-99213)APC 606 (99214)APC 607 (99215)Time-based or complexity-based can be used to choose appropriate 99211-99215 (see table above)Can bill Medicare, Medicaid (SD?), third party payer, and self-pay. Self-insured employers have no option to bill facility feeBill all payers the same, knowing reimbursement will be different Business PlanCreate hospital CPT code with billing department so that ONLY facility fee is charged and NOT professional feeCreate protocol and collaborative practice agreementCalculate Pro Forma on projected reimbursement, not chargesDecide how much revenue goes to the provider office vs pharmacistExample: 5% staff, 15% physician group, 80% pharmacistIncident ToServices performed incident to physician professional services in the physician’s officeRequirementsDirect supervisionServices provided incidental to provider’s professional services in the course of diagnosis or treatmentPhysician-patient relationship; physician must have seen the patient before and continue to regularly see the patientMust be furnished on a provider’s referralService must be commonly done in practice (part of a physician’s normal bill)Pharmacist must be an employee, leased employee, or independent contractor of the physicianAs long as there is financial expense (even office space, IT support, exam room, etc) to the physicianAppointment must be on a separate day from other physicians in the same departmentServicesWide variety of services: anticoag, BP, HLD, diabetes, CHF, transplant, pain, etc99211 Documentation: Requires chief complaint, diagnosis or treatment options, time, and time spent with the patient BillingBill 99211 on a CMS 1500 form using the physician’s NPI. May include an internal provider number (non-billable number) to track patients seen by the pharmacistCan bill Medicare, Medicaid (SD?), third party payer, and self-pay. Self-ensured employers typically are contract based and pay bill 99211 or fixed rate per member per month.Reimbursement 85% for incident to non-physician practitioners (PA, NP,certified nurse midwife, certified nurse specialist)Reimbursement from Medicare 2015: $19.91Bill all payers the same, knowing reimbursement will be differentBusiness PlanCreate protocol and collaborative practice agreementDecide how much revenue goes to the provider office vs pharmacistExample: 5% staff, 15% physician group, 80% pharmacistImmunizationsRequirementsFor Part B vaccines, must enroll in a Medicare program with a provider numberIn clinic, bill under a physician’s Medicare B numberFor pharmacies, obtain a Medicare provider number using form CMS-855General supervisionServicesPart B vaccines – Influenza, pneumococcal, Hepatitis BThe diagnosis codes to report with these preventive vaccines are:V04.81 when influenza vaccine is administered but pneumococcal is notV06.6 when both the influenza and pneumococcal vaccines are administeredV03.82 when administering pneumococcal vaccine but not the influenza vaccineV05.3 when administering the hepatitis B vaccinePart D vaccines – all other vaccines, including Zostavax?Part D costs include cost of vaccine and administration, so a separate administration fee cannot be usedBillingPart B vaccinesInfluenza: once per flu season (codes 90653-90657, 90660-90662, 90672-90673, 90685-90688, Q2034-Q2039) and G0008 for administrationPneumococcal: (codes 90670, 90732, once per lifetime with high-risk booster after 5 years) and G0009 for administrationHepatitis B: for persons at intermediate- to high-risk (codes 90739- 90740, 90743-90744, 90746-90747) and G0010 for administrationPart D vaccinesFor pharmacies, run through as a prescription under the vaccine NDCFor clinicsWeb-Assisted Physician Billing: Enroll with a commercial company portal for Part D vaccine- office must agree to accept payment in full- Patient pays directly to physician deductible, co-pay/co-insurance/cost share. Transactrx- vaccine billing portal: to check cost to patient prior to administrationNo enrollment fee, or fee for e-payments (small fee for paper re-imbursement)Authorization from Part D plan: Physician or patient contacts plan to obtain vaccine-specific notice. Provides info on obtaining authorization, submitting claim, cost-sharing info, and reimbursement rates.In-Network Pharmacy Distribution to Physician: Rx sent to pharmacy (physically/electronically), pharmacy fills and bills Part D, patient pays pharmacy cost shares, pharmacy ships/delivers vaccine, physician office administers vaccine, patient pays administration fee. *Complicated*Business PlanCreate protocol and collaborative practice agreementNeed CPA with each physician to be able to initiate vaccinations for their patients; Cannot use CPA for patient’s outside that physician’s panelLaboratory ServicesRequirementsMust be CLIA-waived labCLIA Certificate of Waiver obtained through CMS-116 ($150)Cannot use if on main hospital campusMust maintain a manufacturer quality assurance log to be available for inspectionNeed a statement of medical necessity and ICD10 codeServicesLaboratory services, typically point of care (POC) devicesBillingBill using CMS 1500 form using CMS Part B Identification Number (PIN)Include statement of medical necessity and ICD10 codeMedication Therapy ManagementRequirementsMust have a national provider identifier. Apply with CMS form 10114Patient must have multiple chronic diseases, taking multiple Part D medications, and have annual Part D drug costs >$31382016 SD will have option for enhanced MTM which will allow for different cutoffs based on planMay want account to use intermediary companies Mirixa, Outcomes and othersServicesTarget medication reviews, typically sent by Outcomes and MirixaComprehensive Medication Review: Review of patient history, medication profile, and recommendations for improving health outcomes and treatment complianceDocumentation: provided to patient and providerPersonal medication listMedication action planBillingBill using CMS 1500 form99605 for a new patient, face-to-face, initial 15 minutes1 per calendar year99606 for an established patient, face-to-face, initial 15 minutes7 per calendar year99607 for each addition 15 minutes, used in addition to 99605 or 996064 per recipient per date of servicePricing may be different based on Part D planBusiness PlanSign up with Mirixa and OutcomesSet up a protocolTransitions of Care2 services included: Interactive communication (non-face-to-face) and face-to-face visitRequirementsPatient discharged from acute care hosptial, rehab hospital, long-term acute care hospital, skilled nursing facility, and community mental health partial hospitalization program and not being discharged to a skilled nursing facility or community mental health center partial hospitalization programInteractive communicationWithin 2 business days of discharge, contact the patient or caregiver by telephone of electronic communication; Must have 2 attempts in 2 business days and must successfully contact patient within 30 daysFace-to-face communication99495: moderate medical decision making (99214) with visit within 14 calendar days of discharge99496: high medical decision making (99215) with visit within 7 calendar days of dischargeMedication reconciliation and management performed no later than date of face-to-face communicationServicesInteractive communication- typically nurse or pharmacistServices may includeObtaining & reviewing recordsReviewing follow-up needsInteraction with other health care professionalsProvider education to patient or caregiverReferrals for community resourcesFace-to-face visit- performed by physician, NP, PA, certified nurse specialist, nurse midwife, pharmacist may help with adherence/med mgmtServices may includeCommunication with agencies and community servicesProvide education to patient and caretakers to support self-management, independent living, and activities of daily livingAssess and support treatment regimen adherence and medication managementIdentify community and health resourcesAssist patient and family in accessing needed care and servicesBillingBundled payment at 99495 ($163.35) or 99496 ($229.47)Submit bill no sooner than 30 days following discharge with date of service 30 days from dischargeOnly 1 provider can bill (provider for face-to-face visit)Not reimbursed if patient dies within the 30 daysCertain billing codes cannot be billed, including MTM, anticoag management (99363, 99364), or end stage renal disease services (90951-90970)Patient pays a 20% copaymentIf not reimbursed can submit for appropriate 99214 or 99215Business PlanCreate protocol and collaborative practice agreementDecide how much revenue goes to the provider office vs pharmacistExample: 5% staff, 15% physician group, 80% pharmacistHow to find current Medicare Fee Schedules:Look up rates professional fees: > “Medicare “> “Physician Fee Schedule Look-up “> “Physician Fee Schedule Search” , hit ACCEPT button, mark PRICING INFORMATION, RANGE OF HCPCS CODES,& SPECIFIC LOCALITY; enter HCPC as “99211 – 99215 or G0108-G0109, etc”, choose modifier as “all modifiers”, and choose carrier/MAC locality as “South Dakota” ................
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