1Workload Capture and Coding Keeping it Simple! National Education Blitz March 2011Sharon Castle, Pharm.D., BCPSChief, Pharmacy ServiceRalph H. Johnson VA Medical CenterCharleston, South Carolina
2HistoryWorkload/Billing Workgroup formed in 2007 to improve documentation of pharmacist encountersLori Golterman, Jan Carmichael, Sharon CastleMilestonesDecision 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 codeExpanded the definition of encounter to include items such as NF reviews, non face to face workloadMajor improvements Nationally with pharmacist documentation
3Future National group expanded to gain further expertise 3 Categories Workload capture documentationContinue national educationAlpha codes specific to pharmacyReportsCorporate Data Warehouse reportsNational DirectiveDraft in review by group
5Progress Reports 160 Primary or Secondary/Pharmacy Unique
6Don’t Miss the Boat What do you need to know to succeed?
7Pharmacy Workload Capture Key Elements Count or Non-count WorkloadFace to Face Telephone“Chart Consult”DSS Identifier SelectionClinic Creation Stop Code/CPT Codes
8Key References Patient Care Data Capture Copayment for Outpatient Care VHA Directive , January 23, 2009Copayment for Outpatient CareVHA Directive , March 5, 2009DSS Outpatient IdentifiersVHA Directive , October 27, 2008All DSS Identifier references are located on the DSS Identifiers web pageWebsite updated annually: References – Reference B (October 1, 2010)DSS Pharmacy Workload Collection Document2008 Telephone Encounter DefinitionsDocument available on SharePointHome Based Primary Care ProgramVHA Handbook , January 31, 2007
9Patient 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 conditionEncounters occur in both the outpatient and inpatient settingWhy document workload?Legal and professional obligationsEncourage consistency throughout VA Clinical Pharmacy Services to ensure count credit for clinical pharmacist servicesAdvance profession
10Count versus Non CountCount 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 workloadA face to face visit is NOT required for countNon-Count activity can be tracked for DSS workload purposes; however, is not transmitted to NPCD in AustinWill 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 DSSPlease review the 2009 presentations on the PBM website under workload and billing process for more information on documenting noncount workload.
11Count versus NonCount Examples Count versus NonCount Examples *Facility specific based on intervention and documentation!Pharmacy InterventionCount*NonCountPharmacist Outpatient ClinicsXTelephone Clinic (med management)Nonformulary ConsultX (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 QuestionEducation ClassesX (despite not always meeting 3 below)*Count = 1. Medical history taken Clinical decision making Documentation in medical record
12Stop Codes (DSS Identifiers) Primary Stop Codes (DSS Identifiers)160 – Clinical PharmacyUse for all clinics except telephone and HBPC147 – 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 specificSecondary Stop Codes (DSS Identifiers)Further defines where pharmacy services takes placeProvides standard reference workload accountingDiscretion left to local Medical Center; however, specificity allows national tracking of pharmacist servicesCertain areas may require deviation from this guidance for special funding or performance measure tracking
13Stop Codes (DSS Identifiers) Selection of Stop Codes/DSS IdentifiersFY11 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/identifierUse of stop code in the primary, secondary or bothDefinition provided for each stop codeMental Health Example - Definitions provide clarity502 – Mental Health Clinic IndividualDefinition: Individual evaluation, consultation and/or treatment by clinical staff trained in mental health diseasesPharmacist can use as a secondary stop509 – Psychiatry – IndividualDefinition: Use by psychiatrist only when care is not delivered in an interdisciplinary settingPharmacist cannot use as a secondary stop (psychiatrist only)
15Common Secondary Stop Codes 323 – Primary care317 – Anticoagulation160 – Clinical PharmacyWill be used in secondary position when a primary stop other than 160 is requiredTelephone, HBPC (see previous slides)306 – Diabetes309 – Hypertension318 – Geriatric Clinic130 – Emergency Department697 – Chart consultAllows intervention to be count but not charge a copayMust have a formal consult
16Chart Consult Non-Face to Face Visits Use for all non-face to face visits that meet the definition of countRequires a formal consult from the provider/team or a policy/business rule at the Medical Center that automatically consults pharmacy for that particular situationUse 697 stop code in the secondary position697 – “Chart Consult” (160/697)Avoids copay (did not see patient face to face)Examples:Pharmacist completing nonformulary requestsPharmacist automatically manages all aminoglycoside dosing
18Alpha Codes 4 letter alpha code Provides further granularity by clinic Limited pharmacy specific codes availableMost major areas will be covered in FY12DSS must enter alpha codes in the DSS side of VISTAThe fileman field is called Clinic and Stop CodesField is not visible to us as part of the clinic profilePlease work with your local DSS staff for addition of alpha codesExample: Inpatient Pharmacokinetics Clinic 160/697, PKPH
19Alpha Codes Available Full List Available On DSS Website CDPHCardiac Disease PharmacistPDCCPulmonary Disease CC TeamCGPHCoag Management PharmacistPDPHPulmonary Disease PharmacistDEPHDementia PharmacistPHRMClinical PharmacyDIABDiabetes EducationPLPHPalliative PharmacistDMCCDiabetes Mellitus CC TeamPNPHPain Management PharmacistDMPHDiabetes Mellitus PharmacistRHPHRehabilitation PharmacistHTCCHypertension CC TeamSCPHSCI PharmacistHTPHHypertension PharmacistSSFUStop Smoke Follow-up – Individual PatientIDCCInfectious Disease CC TeamWCPHWound Care PharmacistIDPHInfectious Disease PharmacistSSGDStop Smoking Group Double ProviderMHCCMental Health CC TeamSPGPSingle Provider – Group of PatientsMHPHMental Health PharmacistSATPSubstance Abuse Treatment ProgramMMPHMultiple Co-Morbidities PharmacistCHOLCholesterol Education - Double Provider
20Alpha Codes Additions as of DSS Patch ECX*3*133 (6/30/2011) CDEDCardiac Disease Education (CHF, etc)NSPHNutritional Support PharmacistCRRCCardiovascular Risk Reduction PharmacistNUCLNuclear Medicine PharmacistCCPHCritical Care PharmacistONCOOncology PharmacistDRPHDermatology PharmacistOPTHOphthalmology PharmacistEDPHEmergency Department PharmacistSPCHSpecialty Care PharmacistESPHESA PharmacistSUPHSurgery/Anesthesia/OR PharmacistHEPCHepatitis C PharmacistPACPPatient Aligned Care Team PharmacistHIVDHIV PharmacistPACTPatient Aligned Care TeamIMPHInternal Medicine PharmacistPGENPharmacogenomics PharmacistMTMPMedication Therapy Management PharmacistPKPHPharmacokinetics PharmacistMRECMedication Reconciliation PharmacistPTPHPolytrauma PharmacistNEURNeurology PharmacistRHUMRheumatology PharmacistNFPANon-Formulary/Prior Approval PharmacistWMPHWomen's Health Pharmacist
21Copay Copay For Outpatient Medical Care Why is this important? DirectiveAttachment B – Defines copay tiers for stop code160 stop code – Basic copay = $15147 stop code – No copay (telephone clinics)Why is this important?Efforts to increase count credit for clinical pharmacy services may result in copay160 Stop Code generates a $15 copayIf they have another visit that day, only 1 copay is chargedIt is inappropriate to choose stop codes based on your desire to charge or not charge a copay
22The Big PictureIs the intervention count?Option 1: Set-up clinic as non-countOption 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.NoYesSeen in clinic?Clinic is set-up with appropriate stop codes stop code will generate $15.00 copay when encounter completedIf 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
23Copay Scenario Count with copay Pharmacist sees patient in hypertension clinicClinic set-up: 160 primary/309 secondaryProgress note enteredHistory and clinical decision making documentedCount (3 ’s)Basic copay charged for 160 stop code
24Copay 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 themselvesClinic set-up: 160 primary/697 secondaryProgress note enteredHistory and clinical decision making documentedCount (3 ’s)Basic copay not charged (697 secondary stop)Requires consult or business rule/policy to use 697May need two clinics, one count and one count with 697 secondaryAnemia (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
25Medication Therapy Management Use New MTM Codes for all face- to-face pharmacist visits99605—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 patient99606—Initial 15 minutes with an established patient99607—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 99606RVUs established by some insurances but not consistentCurrently 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)
26MTM 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 positionUse MTM CPT codesMark 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.
27Clinic-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 AustinEncounter 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
28CPT 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 discussionminutes of medical discussionminutes of medical discussion
29CPT Codes Chart Consult Interpretation of Data Stored in a ComputerEncounter that collects and reviews data with documentationminutesor more minutesUse for encounters (count workload) that you have a secondary stop of 697.Example: Non-formulary reviewsConsult with facility compliance staff on utilization
30Secure 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.”
31Billable/Nonbillable Option Option available in MCCR packageWork closely with billing staff to ensure billable clinics are marked billableNot all facilities are aware that institutional fees can be billed for pharmacy clinicsGeneric recommendationsFace to face – mark billableNon Face to Face – mark nonbillableMark clinic nonbillable to avoid coding staff misinterpreting a note and thinking it is a face to face, billable clinic
32Clinic 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 operationsso you should have your work pre-planned before using this option.
33Clinic 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
34Where to Begin? Document high volume clinical activities at your site Count or noncount for each activityClinic set-upCheck stop codes of current clinicsSet-up clinics for high volume activities that do not have a clinic currently (inpatient!)Select appropriate CPT codes for the clinicsDevelop policies/business rules for activities that do not require consultEducate staff – encounters, how to documentListen for issues/concerns from staff
35Questions 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 99211Face to face – use MTM codes!
36Questions 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?ClinicsNFsInpatient (med rec, kinetics, anticoagulation, etc)
38Questions? Count? (3 ’s required) 1. Medical history taken? 2. Clinical decision making? 3. Documented?
39Screen 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
40Inpatient Encounter Example The following slides are the steps to complete an encounter for an inpatient interactionIt is imperative that the location be changed to the appropriate location (inpatient clinic) for inpatient notes
41Click 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
42Click on “Clinic Appointments” if appointment exists and select it to link the note to existing appointment.
43If no appointment exists, click on NEW VISIT, enter name of clinic (location) and time of appointment (encounter).
44This 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
46Click 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 ACTIONSign Note NowClick encounter button after note is signed
47Click 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.
48Clinical Video Telehealth http://vaww. telehealth. va
49Clinical 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) = 690One 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)
50Care Coordination/Home Telehealth Program growth, frequent changesDetailed guidance on documentation coming out soonCoding requires CCHT codes in primary and secondary positionCommon primary stop codes674, 683, 685, 686Common secondary stop codes179, 371, 684Due to lack of pharmacy specific codes, excellent place to use alpha codes
51Care 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.