Workload Capture and Coding Keeping it Simple! National Education Blitz March 2011

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

2. 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

3. 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

4. Progress ReportsFacility Specific

5. Progress Reports 160 Primary or Secondary/Pharmacy Unique

6. Don’t Miss the BoatWhat do you need to know to succeed?

7. Pharmacy Workload Capture Key Elements

8. Key References • Patient Care Data Capture • VHA Directive 2009-002, January 23, 2009 • Copayment for Outpatient Care • VHA Directive 2009-012, March 5, 2009 • DSS Outpatient Identifiers • VHA Directive 2008-069, October 27, 2008 • All DSS Identifier references are located on the DSS Identifiers web page http://vaww.dss.med.va.gov/programdocs/pd_oident.asp • Website updated annually: 2011 References – Reference B (October 1, 2010) • DSS Pharmacy Workload Collection Document • http://vaww.dss.med.va.gov/programdocs/pd_clinictop.asp • 2008 Telephone Encounter Definitions • Document available on SharePoint • Home Based Primary Care Program • VHA Handbook 1141.01, January 31, 2007

9. PatientEncounters • 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

10. Count versus Non Count • Count refers to activity that meets the definition of an encounter (PCDC VHA Directive 2009-002) • 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.

11. Count versus NonCount Examples*Facility specific based on intervention and documentation!

12. 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

13. Stop Codes (DSS Identifiers) • Selection of Stop Codes/DSS Identifiers • http://vaww.dss.med.va.gov/programdocs/pd_oident.asp • 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)

14. DSS Active IdentifiersReference B

15. 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

16. Chart ConsultNon-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

17. Stop Codes

18. 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

19. Alpha Codes AvailableFull List Available On DSS Website

20. Alpha CodesAdditions as of DSS Patch ECX*3*133 (6/30/2011)

21. Copay • Copay For Outpatient Medical Care • Directive 2009-012 • 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

22. 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. Is the intervention count? No No Copay Count? (3 ’s required) Medical history taken?  Clinical decision making?  Documented?  Yes Seen in clinic? Yes No *Ideal to allow capture as count *Should be used if a high volume of interventions fall into this category *Maximize count/no copay! Clinic is set-up with appropriate stop codes. 160 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  *Lost count workload *Less desirable *Should only be used in low volume scenarios where you do not mind losing count credit The Big Picture

23. Copay ScenarioCount 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

24. Copay ScenarioCount 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

25. 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 99605 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)

26. MTM Codes Inpatient/Chart Consults Inpatient 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.

27. Clinic-Based Telephone Care • VHA Directive 2009-002 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

28. CPT CodesNon Physician Services - Telephone • 98966 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 • 98967 11-20 minutes of medical discussion • 98968 21-30 minutes of medical discussion

29. CPT CodesChart Consult • Interpretation of Data Stored in a Computer • Encounter that collects and reviews data with documentation • 99090 0-29 minutes • 99091 30 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

30. Secure Messaging • Primary stop code: 160 / Secondary stop code: 719 • CPT Code: 98969 (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.”

31. 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

32. 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.

33. 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: 010108  (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

34. 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

35. 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!

36. 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)

37. Clinic Set-Up

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

39. 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

40. 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

41. 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

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

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

44. 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

45. Write note as you normally would.

46. 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

47. 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.

48. Clinical Video Telehealthhttp://vaww.telehealth.va.gov/telehealth/index.asp

49. 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)

50. Care Coordination/Home Telehealth • Program growth, frequent changes • Detailed guidance on documentation coming out soon • http://vaww.telehealth.va.gov/telehealth/index.asp • 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