Here is how to access everything you need to know about these updates.
Our team has extensively researched CMS’s 2022 CPT code updates and compiled them into six easy-to-understand Advanced Learning Lessons (ALLs). The ALLs include everything you need to know about the billing models, CPT codes, reimbursement rates, patient criteria, documentation, and other program details.
The ALLs will help consultant pharmacists to implement Advanced Pharmacy Programs with confidence. In fact, two peer reviews conducted by practicing consultant pharmacists were done on this information, ensuring accuracy and reliability and providing a streamlined approach to implementation.
Why should pharmacists be aware of CPT code updates?
We recommend only a few CPT codes, but the versatility of the codes is unique to the Pharmapreneur Academy™ Advanced Learning Lessons (ALLs).
In our ALL program, we divide our recommendations specifically for consultant pharmacists into two scenarios: Remote Services and Direct Supervision services.
(If you are interested in working with Cash-Pay Patients or in a Pharmacy-Based Setting, those trainings are contained in other ALL and BBB modules)
Remote Care Services
Remote care services are provided under general supervision, which means that when the billing practitioner does not personally perform the service, it is performed under their overall direction and control. However, their physical presence is not required.
Remote services include chronic care management (CCM), principal care management (PCM), remote physiologic monitoring (RPM), and transitional care management (TCM). With CMS encouraging an increase in pursuing telehealth and other remote services, many of these programs have seen an increase in reimbursement rates in 2022.
CCM is a care coordination service provided by practitioners and their clinical staff for patients with two or more chronic conditions expected to last at least 12 months or until the patient’s death, placing the patient at risk of death, acute exacerbation, decompensation, or functional decline.
CCM involves non-face-to-face clinical staff time that is performed outside the regular office visit, including but not limited to clinical phone calls, medication management and refills, chart review, referrals, and other care coordination activities.
This service provides reimbursement when at least 20 minutes of clinical non-face-to-face time has been documented in a calendar month. CCM services are primarily provided by primary care providers, and only one provider can bill CCM codes per patient each month.
Unlike CCM, PCM can be billed by multiple providers per patient each month and is typically used by specialists, such as endocrinologists or cardiologists.
PCM is a care management service for patients with one complex chronic condition lasting at least three months, which is of sufficient severity to place the patient at risk of hospitalization or has been the cause of a recent hospitalization (e.g., diabetes or heart failure). PCM codes can be billed with at least 30 minutes of clinical time that has been documented in a calendar month.
Remote Physiologic Monitoring (RPM) is a care management service that allows providers and their clinical staff to monitor patient-reported physiological data, including but not limited to blood pressure, glucose readings, and weight, through interactive communication with the patient or caregiver.
RPM codes can be billed when at least 20 minutes of RPM care management time has been documented in a calendar month. Providers can bill for RPM & CCM within the same calendar month. However, time spent managing the patient cannot be counted toward the required time for both RPM and CCM.
Transitional Care Management (TCM) is a service provided by healthcare providers and their staff to manage and coordinate care for patients after certain types of hospital discharges.
These services are performed to avoid costly hospital readmissions and other adverse health events.
Although not all elements of TCM can be provided by a pharmacist, the non-face-to-face elements such as the initial interactive contact and medication reconciliation may be completed remotely by a pharmacist.
The TCM code may be billed by the provider based on the complexity of medical decision-making required, as well as the time frame between hospital discharge and the face-to-face visit.
Direct Supervision Services
Direct supervision services involve pharmacists being present in-office, and they include the annual wellness visit (AWV) and evaluation & management (E&M). Both of these visit types must be billed “incident to” the billing provider.
The AWV is an annual visit dedicated to the creation or update of a personalized prevention plan for patients to help prevent illness based on their current health and risk factors.
AWVs must also include reviewing and updating the patient’s health risk assessment, medical history, care team, medication list, vital signs, and screening for cognitive impairment. Pharmacists may provide both initial and subsequent AWVs without a co-visit with the billing provider. In addition to reviewing the required elements of an AWV, pharmacists are uniquely positioned to provide more comprehensive counseling based on the identified risks (e.g., smoking cessation) and bill the counseling codes during the AWV.
E&M services include face-to-face or telehealth visits of an established patient under the direct supervision of a provider.
Unlike the codes above, E&M codes can be billed under any type of insurance, not just Medicare. Some examples may include weight loss visits, chronic disease management services, and pharmacogenomic testing reviews.
If the patient is only seen by the pharmacist, only a level 1 office visit may be billed. Co-visits with other providers allow higher-level office visits to be billed based upon the complexity of medical decision-making required.
Physician’s Office Pharmapreneurial™ Path for Remote and Directly Supervised Services
I. Monica works as an embedded clinical pharmacist at a primary care office. She offers glucose monitoring services using the remote physiologic monitoring code for insulin-dependent diabetic patients as well as in-person visits under the direct supervision of a physician.
While reviewing a new patient’s medications, she noticed he had refilled his glucagon injection, a medication reserved for severe hypoglycemia, eight times, according to his recent refill history.
After investigating further and speaking with the patient, it was clear the patient was using it to bring up blood sugars he ‘thought were too low.’
She was able to intervene, explaining about the emergency use of delivering a subcutaneous injection of glucose and helping him formulate a better strategy for handling mild to moderate hypoglycemia. The per-orem administration of glucose, by comparison, did not cause his blood glucose to skyrocket and ultimately translated to a lower A1c after a few months.
She was able to use her unique experience as a pharmacist to spot the issue, educate her patient and work with him to have a better result. Her intervention also prevented improper use of a life-saving medication and saved money for both the patient and the payer.
Not only does her work show a positive ROI for pharmacist-led services, but also how a consultant pharmacist contributes to better patient outcomes and long-term quality of healthcare by catching
II. The second area of opportunity is for independent pharmacy owners. Pharmacy owners can partner up with different physician offices and offer remote services, such as chronic care management (CCM) or remote physiologic monitoring (RPM).
Pharmacist Erin works as a clinical pharmacist at an independent pharmacy that is contracted with a few small private practices in the area. She provides CCM and RPM services remotely via an online platform for all of the enrolled Medicare patients and also has access to their cloud-based EMRs. At the end of the month, she sends a billing summary to each individual practice to bill for the patients who met the time quota for CCM/RPM that month.
As a part of her CCM services, Erin completes all of the prior authorizations and patient assistance paperwork for the Medicare patients within the contracted practices. Both the patients and providers have found this process to be significantly more efficient, given she also has access to the resources in the dispensing side of the pharmacy. This has resulted in increased patient access to medications, increased satisfaction among both patients and providers, and increased revenue for the practices, given completion of these items count towards monthly clinical staff time for CCM.
III. The third opportunity for pharmacists lies in preventative care services on a cash-pay basis. Patients who are still considered pre-diabetic or pre-hypertensive, and even those who aren’t currently taking any medications, can greatly benefit from a conversation with a consultant pharmacist on lifestyle medicine. A holistic approach helps to maintain or improve health and well-being and avoid disease progression.
Pharmacist Monica focuses on preventative lifestyle modification programs. She works with non-prescribing providers such as functional neurologists, naturopaths, and chiropractors.
Her patients are most commonly experiencing autonomic dysfunction and are on a whole different array of medications such as steroids, beta-blockers, anxiolytics, antidepressants, etc. She works with these patients to help optimize their medication use or in some cases, even de-prescribing medications.
Pharmacists like these are paving the way for an evolution in the practice of pharmacy.
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