March 2011 Sharon Castle, Pharm.D., BCPS Chief, Pharmacy Service

Workload Capture and Coding Keeping it Simple! National Education Blitz
March 2011 Sharon Castle, Pharm.D., BCPS Chief, Pharmacy Service Ralph H. Johnson VA Medical Center Charleston, South Carolina

History Workload/Billing Workgroup formed in 2007 to improve documentation of pharmacist encounters Lori Golterman, Jan Carmichael, Sharon Castle Milestones Decision to use Patient Care Encounter system to document outpatient and inpatient workload (PCE, not event capture) 160 (clinical pharmacy stop code) approved for use as a primary stop code Expanded the definition of encounter to include items such as NF reviews, non face to face workload Major improvements Nationally with pharmacist documentation

Future National group expanded to gain further expertise 3 Categories
Workload capture documentation Continue national education Alpha codes specific to pharmacy Reports Corporate Data Warehouse reports National Directive Draft in review by group

Progress Reports Facility Specific

Progress Reports 160 Primary or Secondary/Pharmacy Unique

Don’t Miss the Boat What do you need to know to succeed?

Pharmacy Workload Capture Key Elements
Count or Non-count Workload Face to Face Telephone “Chart Consult” DSS Identifier Selection Clinic Creation Stop Code/ CPT Codes

Key References Patient Care Data Capture Copayment for Outpatient Care
VHA Directive , January 23, 2009 Copayment for Outpatient Care VHA Directive , March 5, 2009 DSS Outpatient Identifiers VHA Directive , October 27, 2008 All DSS Identifier references are located on the DSS Identifiers web page Website updated annually: References – Reference B (October 1, 2010) DSS Pharmacy Workload Collection Document 2008 Telephone Encounter Definitions Document available on SharePoint Home Based Primary Care Program VHA Handbook , January 31, 2007

Patient Encounters Patient Care Data Capture, VHA Directive 2009-002
An encounter is a professional contact between a patient and a practitioner vested with responsibility for diagnosing, evaluating, and treating the patient’s condition Encounters occur in both the outpatient and inpatient setting Why document workload? Legal and professional obligations Encourage consistency throughout VA Clinical Pharmacy Services to ensure count credit for clinical pharmacist services Advance profession

Count versus Non Count Count refers to activity that meets the definition of an encounter (PCDC VHA Directive ) Count activity requires (3 ’s): A corresponding progress note in CPRS  Documentation must include medical history  Documentation must include clinical decision making  VA PBM goal to increase count workload A face to face visit is NOT required for count Non-Count activity can be tracked for DSS workload purposes; however, is not transmitted to NPCD in Austin Will only transmit to DSS for workload if done through a noncount clinic/will not transmit if “historical” checked. This presentation will not review noncount workload capture for DSS Please review the 2009 presentations on the PBM website under workload and billing process for more information on documenting noncount workload.

Count versus NonCount Examples
Count versus NonCount Examples *Facility specific based on intervention and documentation! Pharmacy Intervention Count* NonCount Pharmacist Outpatient Clinics X Telephone Clinic (med management) Nonformulary Consult X (Formal consult or business rule required + progress note by pharmacist with documenting count activity) Telephone calls from patients asking questions (medication been mailed, prescription refills, etc) Inpatient consults (pharmacokinetics, anticoagulation, etc) X (Formal consult or business rule/policy for pharmacy to follow + progress note by pharmacist documenting count activity) Pharmacy Interventions (CrCl adjustments, drug-drug interactions) Drug Information Question Education Classes X (despite not always meeting 3 below) *Count = 1. Medical history taken Clinical decision making Documentation in medical record

Stop Codes (DSS Identifiers)
Primary Stop Codes (DSS Identifiers) 160 – Clinical Pharmacy Use for all clinics except telephone and HBPC 147 – Telephone clinics (Required to use as primary) 324 – PACT telephone clinics (Required to use for PACT) Must use 324/323 in FY11 (New PACT codes in FY12) 176 – HBPC Clinical Pharmacist (Required to use as primary) 178 – HBPC telephone (Required to use as primary) Not pharmacy specific Secondary Stop Codes (DSS Identifiers) Further defines where pharmacy services takes place Provides standard reference workload accounting Discretion left to local Medical Center; however, specificity allows national tracking of pharmacist services Certain areas may require deviation from this guidance for special funding or performance measure tracking

Stop Codes (DSS Identifiers)
Selection of Stop Codes/DSS Identifiers FY11 Summary of Active DSS Identifiers (Reference B on website) Midyear changes/updates (For example, 348, PC Shared Medical Appointment) Provides detail on each stop code/identifier Use of stop code in the primary, secondary or both Definition provided for each stop code Mental Health Example - Definitions provide clarity 502 – Mental Health Clinic Individual Definition: Individual evaluation, consultation and/or treatment by clinical staff trained in mental health diseases Pharmacist can use as a secondary stop 509 – Psychiatry – Individual Definition: Use by psychiatrist only when care is not delivered in an interdisciplinary setting Pharmacist cannot use as a secondary stop (psychiatrist only)

DSS Active Identifiers Reference B

Common Secondary Stop Codes
323 – Primary care 317 – Anticoagulation 160 – Clinical Pharmacy Will be used in secondary position when a primary stop other than 160 is required Telephone, HBPC (see previous slides) 306 – Diabetes 309 – Hypertension 318 – Geriatric Clinic 130 – Emergency Department 697 – Chart consult Allows intervention to be count but not charge a copay Must have a formal consult

Chart Consult Non-Face to Face Visits
Use for all non-face to face visits that meet the definition of count Requires a formal consult from the provider/team or a policy/business rule at the Medical Center that automatically consults pharmacy for that particular situation Use 697 stop code in the secondary position 697 – “Chart Consult” (160/697) Avoids copay (did not see patient face to face) Examples: Pharmacist completing nonformulary requests Pharmacist automatically manages all aminoglycoside dosing

Stop Codes Clinic Stop Code Credit Stop Code
Warfarin Clinic (Face to Face) 160 317 (Anticoag) Warfarin Clinic (Telephone) 147 Hypertension Clinic 309 (Hypertension) Diabetes Clinic 306 (Diabetes) Epogen (Anemia) Clinic 308 (Hematology) HBPC Warfarin Clinic 176 317 HBPC Warfarin Telephone 178 Infectious Disease Clinic 310 Geriatric Clinic 318 Geriatric Evaluation and Management 319 (Geriatric Specialist)

Alpha Codes 4 letter alpha code Provides further granularity by clinic
Limited pharmacy specific codes available Most major areas will be covered in FY12 DSS must enter alpha codes in the DSS side of VISTA The fileman field is called Clinic and Stop Codes Field is not visible to us as part of the clinic profile Please work with your local DSS staff for addition of alpha codes Example: Inpatient Pharmacokinetics Clinic 160/697, PKPH

Alpha Codes Available Full List Available On DSS Website
CDPH Cardiac Disease Pharmacist PDCC Pulmonary Disease CC Team CGPH Coag Management Pharmacist PDPH Pulmonary Disease Pharmacist DEPH Dementia Pharmacist PHRM Clinical Pharmacy DIAB Diabetes Education PLPH Palliative Pharmacist DMCC Diabetes Mellitus CC Team PNPH Pain Management Pharmacist DMPH Diabetes Mellitus Pharmacist RHPH Rehabilitation Pharmacist HTCC Hypertension CC Team SCPH SCI Pharmacist HTPH Hypertension Pharmacist SSFU Stop Smoke Follow-up – Individual Patient IDCC Infectious Disease CC Team WCPH Wound Care Pharmacist IDPH Infectious Disease Pharmacist SSGD Stop Smoking Group Double Provider MHCC Mental Health CC Team SPGP Single Provider – Group of Patients MHPH Mental Health Pharmacist SATP Substance Abuse Treatment Program MMPH Multiple Co-Morbidities Pharmacist CHOL Cholesterol Education - Double Provider

Alpha Codes Additions as of DSS Patch ECX*3*133 (6/30/2011)
CDED Cardiac Disease Education (CHF, etc) NSPH Nutritional Support Pharmacist CRRC Cardiovascular Risk Reduction Pharmacist NUCL Nuclear Medicine Pharmacist CCPH Critical Care Pharmacist ONCO Oncology Pharmacist DRPH Dermatology Pharmacist OPTH Ophthalmology Pharmacist EDPH Emergency Department Pharmacist SPCH Specialty Care Pharmacist ESPH ESA Pharmacist SUPH Surgery/Anesthesia/OR Pharmacist HEPC Hepatitis C Pharmacist PACP Patient Aligned Care Team Pharmacist HIVD HIV Pharmacist PACT Patient Aligned Care Team IMPH Internal Medicine Pharmacist PGEN Pharmacogenomics Pharmacist MTMP Medication Therapy Management Pharmacist PKPH Pharmacokinetics Pharmacist MREC Medication Reconciliation Pharmacist PTPH Polytrauma Pharmacist NEUR Neurology Pharmacist RHUM Rheumatology Pharmacist NFPA Non-Formulary/Prior Approval Pharmacist WMPH Women's Health Pharmacist

Copay Copay For Outpatient Medical Care Why is this important?
Directive Attachment B – Defines copay tiers for stop code 160 stop code – Basic copay = $15 147 stop code – No copay (telephone clinics) Why is this important? Efforts to increase count credit for clinical pharmacy services may result in copay 160 Stop Code generates a $15 copay If they have another visit that day, only 1 copay is charged It is inappropriate to choose stop codes based on your desire to charge or not charge a copay

The Big Picture Is the intervention count? Option 1: Set-up clinic as non-count Option 2: Link to count clinic (if one exists) but check historical box on encounter *Example of #2: To document “noncount” interventions in a warfarin clinic set up with a 160/317 stop code Will not require a second noncount clinic but not DSS workload credit. No Yes Seen in clinic? Clinic is set-up with appropriate stop codes stop code will generate $15.00 copay when encounter completed If formal consult or business rule/policy: Option 1: To gain count credit, a separate clinic will need to be created with a secondary stop of 697 to avoid a copay  Option 2: Can be seen in clinic without 697 as secondary stop but must be marked historical to avoid a copay, results in no count credit  Count? (3 ’s required) Medical history taken?  Clinical decision making?  Documented?  No Copay *Ideal to allow capture as count *Should be used if a high volume of interventions fall into this category *Maximize count/no copay! *Lost count workload *Less desirable *Should only be used in low volume scenarios where you do not mind losing count credit

Copay Scenario Count with copay
Pharmacist sees patient in hypertension clinic Clinic set-up: 160 primary/309 secondary Progress note entered History and clinical decision making documented Count (3 ’s) Basic copay charged for 160 stop code

Copay Scenario Count without copay based on clinic set-up
Pharmacist reviews patient history and documentation to ensure appropriate lab work is completed, correct dosing, and provides recommendations to the provider or fulfills the recommendations themselves Clinic set-up: 160 primary/697 secondary Progress note entered History and clinical decision making documented Count (3 ’s) Basic copay not charged (697 secondary stop) Requires consult or business rule/policy to use 697 May need two clinics, one count and one count with 697 secondary Anemia (EPO) clinic with pharmacist seeing patient in clinic (160/308) Anemia (EPO) clinic with pharmacist completing review as above (160/697) Allows you to obtain count workload without charging a copay

Medication Therapy Management
Use New MTM Codes for all face- to-face pharmacist visits 99605—MTM service(s) provided by a pharmacist to an individual patient during a face-to-face encounter that involve an assessment and intervention if provided; used to code the initial 15 minutes of an initial encounter with a new MTM patient 99606—Initial 15 minutes with an established patient 99607—Each additional 15 minutes of an initial or subsequent MTM encounter; list separately in addition to code for primary service and in conjunction with or 99606 RVUs established by some insurances but not consistent Currently billing institutional/facility fee $141 (if multiple visits that day, only 1 fee billed) Future goal: Establish payment structures for MTM within contracts Nationally (CBO responsibility)

MTM Codes Inpatient/Chart Consults
Q: Can we use these new MTM CPT codes for inpatient services? A: The new CPT codes were designed to be applicable for all pharmacy practice environments and circumstances. The answer depends on whether payers include inpatient pharmacist services in their spectrum of covered benefits and whether the pharmacist is an employee of the institution or a private practitioner. If a payer recognizes inpatient pharmacist services as a separate billable service, the pharmacist should be able to use these codes and get reimbursed as per the agreement with the payer. VA bills one fee for inpatient services, rolling ancillary services into one DRG; billing of the MTM codes for inpatient is therefore, irrelevant. However, it is very important to set up clinics to capture workload. Chart Consults (Pharmacist Encounter – Not Face to Face) Stop code 697 in the secondary position Use MTM CPT codes Mark clinic nonbillable in MCCR package to avoid coding/billing staff seeing this as a face to face, billable clinic (see slide 30) It is no longer recommended to use 99090/99091.

Clinic-Based Telephone Care
VHA Directive Patient Care Encounters defines telephone encounter: A telephone contact between a practitioner and a patient is only considered an encounter (count) if the telephone contact is documented and that documentation includes the appropriate elements of a face-to-face encounter, namely history and medical decision-making. Telephone encounters must be associated with a telephone clinic that is assigned one of the DSS telephone three-digit identifiers. Telephone encounters are to be designated as non-billable and are count clinics. Most clinic-based pharmacist telephone care are encounters and therefore should be “count” clinics with documentation in the chart and workload sent to Austin Encounter is a professional contact between a patient and a practitioner vested with responsibility for diagnosing, evaluating, and treating the patient’s condition. As always, certain type of telephone ‘visits’ do not count and will be documented as either a historical visit or as a note addendum. Examples: Appointment reminder, Follow-up after visit, Lab test results received day after the visit

CPT Codes Non Physician Services - Telephone
Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion minutes of medical discussion minutes of medical discussion

CPT Codes Chart Consult
Interpretation of Data Stored in a Computer Encounter that collects and reviews data with documentation minutes or more minutes Use for encounters (count workload) that you have a secondary stop of 697. Example: Non-formulary reviews Consult with facility compliance staff on utilization

Secure Messaging Primary stop code: 160 / Secondary stop code: 719
CPT Code: (online assessment and management) The service being reported with this code cannot be a continuation of a service that was provided within the previous seven days. There is ONE option for directly saving secure messages from the SM application as TIU notes. A single location of “Other” is the default location and this location creates a “historical” note. Workload cannot be captured utilizing a “historical” note. All notes saved directly from the secure messaging system to CPRS are saved as a historical note. Workload Credit: For the limited number of messages that meet the criteria for an online evaluation, the author may utilize the copy and paste functionality to copy a secure message, in its entirety, from the SM application to create a note that is associated with a count, non-billable clinic specifically set up to capture secure messages. The clinic must utilize the secondary stop code 719 to ensure all first and third party billing is suppressed and to allow for accurate capture of information. All notes that are copied and pasted from the SM application are mapped to the standard note title “My HealtheVet (MHV) Dialog Note.”

Billable/Nonbillable Option
Option available in MCCR package Work closely with billing staff to ensure billable clinics are marked billable Not all facilities are aware that institutional fees can be billed for pharmacy clinics Generic recommendations Face to face – mark billable Non Face to Face – mark nonbillable Mark clinic nonbillable to avoid coding staff misinterpreting a note and thinking it is a face to face, billable clinic

Clinic Nonbillable - VISTA
Select MCCR System Definition Menu Option: FLTP Flag Stop Codes/Clinics for Third Party Flag Stop Codes and Clinics for Third Party Billing =============================================================================== FOR THIRD PARTY BILLING, THIS OPTION IS USED TO SET UP: 1. INDIVIDUAL OR A GROUP OF STOP CODES OR CLINICS AS: a. NON-BILLABLE OR BILLABLE. A Stop/Clinic is assumed billable until it is flagged as non-billable. b. IGNORED BY THE AUTO BILLER. Stops the auto biller from creating bills for specified billable Stops/Clinics. 2. ALL CLINICS TO BE: a. IGNORED BY THE AUTO BILLER. Stops the auto biller from creating bills for ALL clinics. Should only be used if the outpatient auto biller is on but only a small number of Clinics should be auto billed. b. BILLED BY THE AUTO BILLER. Resets all Clinics to be auto billed. Use of this option will have an immediate effect on your billing operations so you should have your work pre-planned before using this option.

Clinic Nonbillable – VISTA (cont.)
Select one of the following: S STOP CODES C CLINICS A ALL CLINICS Enter your choice: CLINICS You may now enter the clinics that you wish to flag. Please note all clinics that you select will be assigned the same effective date and billable status and auto bill status. Select CLINIC: DERMATOLOGY-TELEPHONE Next CLINIC: Is this clinic Non-Billable for Third Party Billing? YES Please enter the date this should become effective: (JAN 01, 2008) DERMATOLOGY-TELEPHONE Effective Jan 01, 2008 the above clinics will be Non-billable and will NOT have bills created by the Third Party auto biller. Is this correct, is it okay to proceed and file these entries? YES Filing these CLINIC entries... . done

Where to Begin? Document high volume clinical activities at your site
Count or noncount for each activity Clinic set-up Check stop codes of current clinics Set-up clinics for high volume activities that do not have a clinic currently (inpatient!) Select appropriate CPT codes for the clinics Develop policies/business rules for activities that do not require consult Educate staff – encounters, how to document Listen for issues/concerns from staff

Questions to Ask Yourself
Are my current stop codes correct? Do face to face visit clinics have 160 in the primary? If 160 isn’t the primary, why? (telephone, hbpc, other) If cannot be in primary, is it in the secondary? Are nonface to face, nontelephone visits, 160 primary and 697 secondary (to avoid copay)? Is everything being documented in these clinics truly count (history taken, clinical decision, documented)? Are we using the appropriate CPT codes? Should no longer be using 99211 Face to face – use MTM codes!

Questions to Ask Yourself
Are my face to face clinics marked billable in the MCCF package? Does my billing/coding staff know they can bill institutional fees for these pharmacy visits? Are the nonface to face visits marked nonbillable? What are we doing that is “count” workload that we aren’t documenting? Clinics NFs Inpatient (med rec, kinetics, anticoagulation, etc)

Clinic Set-Up

Questions? Count? (3 ’s required) 1. Medical history taken? 
2. Clinical decision making?  3. Documented? 

Screen Captures: Inpatient Encounters
It is imperative that the location be changed to the appropriate location (inpatient clinic) for inpatient notes *Disclaimer: Facility variation may occur

Inpatient Encounter Example
The following slides are the steps to complete an encounter for an inpatient interaction It is imperative that the location be changed to the appropriate location (inpatient clinic) for inpatient notes

Click on the location box directly next to the patient data box, found in the upper left corner of the screen. ***For INPATIENT NOTES, the location MUST be changed FIRST in order for productivity/workload to be credited to the clinic. Location block

Click on “Clinic Appointments” if appointment exists and select it to link the note to existing appointment.

If no appointment exists, click on NEW VISIT, enter name of clinic (location) and time of appointment (encounter).

This is the area that consults will appear, if applicable
Click on NEW NOTE, enter name of note title you wish to use. ****If there is a consult associated with visit, choose “CONSULT” title to close consult at same time note is written. With active consults, an additional dialog box will appear at bottom of Progress Note Properties box. This is the area that consults will appear, if applicable

Write note as you normally would.

Click encounter button after note is signed
Click “Action, Sign Note Now”. For NON-COUNT clinics, you will NOT be prompted for encounter data. Sign note. You MUST click encounter button after signing note. ***COUNT CLINICS: Encounter data MUST be entered before SIGNING note. Click ACTION Sign Note Now Click encounter button after note is signed

Click encounter button and enter encounter data as usual
Click encounter button and enter encounter data as usual. Be sure to answer service connected and rated disabilities questions, visit type and/or procedure and diagnosis code to satisfy encounter. This will provide DSS with workload.

Clinical Video Telehealth http://vaww. telehealth. va

Clinical Video Telehealth
Two clinic appointments must be made for these visits: One appointment at the patient site with the following secondary DSS Identifiers (stop code): Patient site (originating site) = 690 One appointment at the provider site. The clinic setups will have the following secondary DSS Identifiers (stop codes): Provider site (distant site) – same station number = 692 (#1 above) Provider site (distant site) – different station number = 693 (situations #2 and #3)

Care Coordination/Home Telehealth
Program growth, frequent changes Detailed guidance on documentation coming out soon Coding requires CCHT codes in primary and secondary position Common primary stop codes 674, 683, 685, 686 Common secondary stop codes 179, 371, 684 Due to lack of pharmacy specific codes, excellent place to use alpha codes

Care Coordination/Home Telehealth
Care Coordination/Home Telehealth *Work with local billing staff for appropriate codes! Patient Site: Use the CPT/HCPCS (Healthcare Common Procedure Coding System) code Q3014, which stands for the Telehealth Originating Site Facility Fee. The thinking is this nominal fee supports the facility (equipment, power, heating, cooling, lighting) providing the patient a place to access care via telehealth. This is the only code that is appropriate for the patient site. For activities performed by clinical staff at the patient site, (e.g., blood pressure, weight, temperature) a separate face to face clinic visit should be set up for documentation. Questions regarding eligibility, Agent Orange and ionizing radiation, need to be answered to complete checkout. Provider site: Use the appropriate CPT code as if the procedure/service was performed face-to-face, but use the realtime telehealth modifier. For example, GT where CPT designates "Neuromuscular Re- Education" and HCPCS modifier code GT designates "Realtime" or "Interactive" telehealth.

CCHT Stop Code Pairs Examples

March 2011 Sharon Castle, Pharm.D., BCPS Chief, Pharmacy Service

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March 2011 Sharon Castle, Pharm.D., BCPS Chief, Pharmacy Service

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