Developing and Managing a Clinical Practice — Ambulatory Care Pharmacy Preparatory Review (ACCP/ASHP 2025)

A comprehensive set of 100 practice-style questions (Question and Answer format) designed to review and reinforce key concepts from the ambulatory care clinical practice lecture notes. Topics include objectives, abbreviations, PCMP processes, environmental scans, SWOT, program management, billing, CMS quality measures, and reimbursement models.

What is Learning Objective 1?

Demonstrate the steps to identify the need for and implement pharmacist-provided patient care services in the ambulatory care setting.

What is Learning Objective 2?

Design a robust and sustainable quality assessment program for pharmacist-provided patient care services in the ambulatory care setting.

What is Learning Objective 3?

Summarize considerations for ongoing management of an ambulatory care service.

What is Learning Objective 4?

Examine revenue-generating opportunities for pharmacist-provided patient care services in different ambulatory care settings.

What does ACO stand for?

Accountable care organization.

What does APC stand for in ambulatory care billing?

Ambulatory Payment Classification.

What does APM stand for?

Alternative Payment Model.

What does AWV stand for?

Annual Wellness Visit.

What does CCM stand for?

Chronic Care Management.

What does CPT stand for?

Current Procedural Terminology.

What does EHR stand for?

Electronic Health Record.

What does HIPAA stand for?

Health Insurance Portability and Accountability Act.

What does HEDIS stand for?

Healthcare Effectiveness Data and Information Set.

What does MTM stand for?

Medication Therapy Management.

What does MIPS stand for?

Merit-Based Incentive Payment System.

What does MSSP stand for?

Medicare Shared Savings Program.

What does NPI stand for?

National Provider Identifier.

What does PCM stand for?

Principal Care Management.

What does PCMH stand for?

Patient-Centered Medical Home.

What does PDSA stand for?

Plan, Do, Study, Act.

What does POCT stand for?

Point-of-Care Testing.

What does QPP stand for?

Quality Payment Program.

What does RHC stand for?

Rural Health Clinic.

What does ROI stand for in this course?

Return on Investment.

What are the six steps of the Pharmacists’ Patient Care Process (PCP Process)?

Collect, Assess, Plan, Implement, Follow up, Document.

What is the purpose of the Pharmacists’ Patient Care Process (PCP Process)?

Deliver Comprehensive Medication Management in patient-centered, team-based care settings.

What is Internal Environmental Scanning?

Collecting internal data to identify current and future needs of the organization to plan pharmacist-provided services.

What is External Environmental Scanning?

Identifying literature, standards, competitors, and best practices from outside the organization to inform proposals.

What does SWOT stand for?

Strengths, Weaknesses, Opportunities, Threats.

Name a Strength of the Traditional, office-based practice model from the SWOT table.

Physician collaboration (and access to patient medical records) are strengths.

Name a Weakness of the Traditional, office-based practice model from the SWOT table.

Fewer communication barriers in some contexts, but often limited physical space and practice constraints.

Name an Opportunity from the SWOT analysis for ambulatory care.

Added services may improve rehospitalization outcomes and reduce penalties.

Name a Threat from the SWOT analysis for ambulatory care.

Billing challenges for expanded services and potential external competition.

What are the key resources for starting a clinical pharmacy program?

Personnel, space, equipment, and supplies.

What percent of MTM time is typically non-patient care according to studies?

Approximately 30% of time.

What is the purpose of IT systems in ambulatory care programs?

To support patient data access, documentation, quality measurement, and billing.

What is CLIA?

Clinical Laboratory Improvement Amendments; regulates lab testing and waivers for POCT.

What is a CLIA waiver?

A waiver for tests deemed to have minimal risk, allowing clinic testing under a CLIA waiver.

What is a CLIA waiver process generally required to do?

Obtain a CLIA waiver, follow test instructions, and manage waste per OSHA/state rules.

What is the typical initial visit time for anticoagulation services?

30–45 minutes initially.

What is the typical follow-up visit time for anticoagulation services?

15–20 minutes.

What is the recommended initial visit duration for high-risk patients with complex conditions?

60 minutes for initial visit and 30–45 minutes for follow-up.

What is the role of a Medical Assistant or Pharmacy Technician in POCT?

They can perform POCT under appropriate training and workflow planning.

What is the Box 2 Pharmacists’ Patient Care Process used for?

Standardizing patient visits and documenting the care plan across the team.

What does Box 3 outline in the suggested timeline for establishing a practice?

An 6-month optimal timeline with phased steps (scans, mission/vision, resources, proposals, etc.).

What are the four areas of the Balanced Scorecard for quality measurement?

Structure, Process, Outcomes, and Financial measures.

What CMS Quality Strategy goals guide quality improvement?

Promote aligned health outcomes, advance equity, ensure safe and resilient systems, accelerate interoperability.

What is MIPS in CMS quality programs?

A track under MACRA that measures performance on quality and improvement activities.

What is an APM (Alternative Payment Model)?

A payment model that rewards value and quality, not just volume of services.

What is an ACO (Accountable Care Organization)?

A voluntary group of providers responsible for the quality and cost of a defined patient population.

What is PCMH (Patient-Centered Medical Home)?

A model of primary care centered on comprehensive, team-based, coordinated care.

What is MACRA?

The Medicare Access and CHIP Reauthorization Act; established MIPS and APMs to move toward value-based payment.

What is the purpose of the QPP?

To implement quality measurement and accountability for payment based on outcomes and value.

What is HEDIS used for?

A set of measures used by commercial payers to evaluate health plans' quality.

What is the role of NQF?

National Quality Forum; endorses health care quality measures.

What is the CPT coding system?

Current Procedural Terminology; used to report medical procedures and services.

What is the HCPCS coding system?

Level I CPT; Level II codes for products and services not in CPT.

What is an RVU?

Relative Value Unit; a component in Medicare reimbursements under RBRVS.

What is the difference between 99211 and higher E/M levels?

99211 is a defined low-level office/outpatient visit; higher levels (99212-99215) require more time and medical decision-making.

What is G0463 in facility fee billing?

A Hospital Outpatient Prospective Payment (HOPPS) code paired with APC 5012 to bill facility outpatient services.

What codes are used for MTM under Medicare Part D?

HCPCS CPT 99605, 99606, and 99607; MTM-related CPT codes.

What does 99490 and 99439 refer to?

CCM codes: 99490 First 20 minutes of clinical staff time; 99439 Each additional 20 minutes.

What does 99487 and 99489 refer to?

Complex CCM: 99487 First 60 minutes by clinical staff; 99489 Each additional 30 minutes.

What are the PCM time-based CCM/PCM billing codes?

PCM uses codes 99424 and 99425 (physician or nonphysician QHP time) and 99426-99427 (clinical staff time).

What are the CMS dwelling codes for Advanced Primary Care Management (APCM)?

G0556 (1 or fewer chronic conditions), G0557 (two or more), G0558 (two or more in Medicare beneficiary).

What is the MDPP program?

Medicare Diabetes Prevention Program; CDC-recognized program with 12 core sessions and 12 maintenance sessions.

What is a DSMT program and who can bill it?

Diabetes Self-Management Training; billed under Part B by a DSMT entity; accreditation required; groups or individuals may be billed (G0108, G0109).

What AWV codes exist under Medicare Part B?

G0438 Initial AWV; G0439 Subsequent AWV; G0402 IPPE; G0468 AWV in FQHC.

What is incident to billing?

An indirect billing mechanism where auxiliary personnel provide services under the supervision of a physician or QHP and bill under the supervisor’s NPI.

What is direct supervision in incident to rules (as updated by CMS)?

Originally physician presence in the same suite; CMS now allows virtual presence for some E/M services through 2025.

What is required to bill outpatient E/M codes under incident to in physician offices?

Service must be medically necessary, an integral part of the supervising provider’s care, and billed under the supervising provider’s NPI.

What is the role of MACs (Medicare Administrative Contractors)?

Contracted private companies that administer Medicare funds, coverage determinations, and claims processing.

What is the Payer parity literature recommended source?

The Advancing Pharmacist Payment Parity Workgroup summaries; state reimbursement parity information.

What is a facility fee in HOPPS outpatient billing?

A hospital facility fee paid to the hospital for using its outpatient facilities; uses APC and G0463 with 5012.

Which box describes a Core quality measure sets for Medicaid (Adult Core Set)?

CMS core set for Medicaid; includes measures that ambulatory pharmacists can influence.

What is the purpose of PDSA in quality improvement?

Plan-Do-Study-Act cycle to test changes and drive iterative improvement.

What is the difference between six sigma and lean in quality improvement?

Six Sigma focuses on reducing variation and defects (3.4 defects per million opportunities); Lean focuses on value and eliminating waste.

What is the JCPP Patient Care Process?

Pharmacists’ Patient Care Process (JCPP) version, a framework for comprehensive medication management.

Which organization published the Standards of Practice for Clinical Pharmacists?

American College of Clinical Pharmacy (ACCP).

What does the term 'credentialing' mean in pharmacy practice?

Verification that a clinician has the appropriate credentials and licensure to practice.

What does 'privileging' mean in pharmacy practice?

Granting permission to perform a defined set of services within an organization.

What is the role of a 'program champion'?

An opinion leader who can influence decisions and support the proposed service.

What are the four stakeholder groups listed for ambulatory care programs?

Physicians/providers, billing/compliance, practice manager, pharmacy staff.

What is the Box 2 content—Pharmacists’ Patient Care Process—Collect step?

Gather necessary subjective and objective patient information and medical/medication history.

What is the Box 2 content—Plan step?

Develop an individualized patient-centered care plan with input from the patient and team.

What is the Box 2 content—Implement step?

Initiate the care plan and educate patients and caregivers.

What is Box 2 content—Follow up step?

Monitor effectiveness of the care plan and modify as needed.

What is Box 2 content—Document step?

Document and communicate services; maintain medication profiles and care plans.

What is Box 3 ‘Optimal Timeline’ Box 3 Box 3 Month 1 activities?

Perform internal/external environmental scans; draft mission/vision; identify stakeholders; review scope of practice; perform a SWOT.

What is Box 3 Month 2 activities?

Convene planning team; finalize mission/vision/goals; determine startup costs; develop a timeline; begin service proposal.

What is Box 3 Months 5-6 activities?

Develop policies/procedures; marketing plan; plan service setup; order equipment; obtain CLIA waivers; prepare for launch.

What is Box 4 ‘Quality Measures’ four key areas?

Structure, Process, Outcomes, and Financial measures.

What is Box 5 CPT Code Categories – Category 1 examples?

Evaluation and Management (E/M) CPT codes 99201-99499; MTM codes 99605-99607; other categories include tests and documents.

What does Box 5 say about 99211?

99211 is the established patient visit code used for minimal or no physician time; often used for incident to services.

What is the difference between 'Category 1' and 'Category 2' CPT codes?

Category 1 are standard CPT codes (e.g., E/M, MTM); Category 2 codes track performance; Category 3 codes are for emerging tech.

What is a G code in DSMT billing?

HCPCS level II code; used to report diabetes self-management education services.

What is the 'G0463' code used for?

Facility fee billing for hospital outpatient services; paired with APC 5012.

What is the 'G0108' DSMT code?

Individual diabetes self-management training visit.

What is the 'G0109' DSMT code?

Group diabetes self-management training visit.

What is the role of the 'NRG' 'Box 1' in literature resources?

Box 1 lists key general literature resources for ambulatory care pharmacy practice.