PCC Exam 1

identify the origins of MTM

- first described in the Medicare Modernization Act of 2003

- required Part D plans to provide MTM services to a defined subset of beneficiaries to optimize therapeutic outcomes by improving medication use, reducing adverse drug events + interactions

Pharmaceutical Care description 1990:

The mission of the pharmacist is to provide pharmaceutical care. Pharmaceutical care is the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patients quality of life.

define medication therapy management:

- a distinct service or group of services that optimize therapeutic outcomes for individual patients

- independent of, but can occur in conjunction with the provision of a medication product

- encompasses a broad range of professional activities + responsibilities w/in the pharmacists (or other healthcare providers) scope of practice

what are some examples of MTM services?

- Medication therapy reviews

- Pharmacy consults

- Disease management coach/support

- Pharmacogenomics applictions

- Anticoagulation applications

- Medication safety surveillance

- Health, wellness, + public health

- Immunization

- Other clinical services

what is Group 1 (Regular Program) for targeted beneficiary in Medicare Part D?

targeted beneficiaries include patients in a Part D plan that fulfill all 3 criteria:

1. Have multiple chronic diseases

2. Take multiple Part D drugs

3. Are likely to incur annual costs for covered Part D drugs exceeding a predetermined level as determined by the Secretary

Medicare dropped the minimum cost requirement to expand eligibility

what is Group 2 (Drug Management Program) for targeted beneficiary in Medicare Part D?

- At-Risk Beneficiaries (ARBs)as defined at § 423.100

- Potential for misuse or abuse of frequently abused drugs

- History of opioid-related overdose or claim for medication used for MAT

- Required targeting started January 1, 2022

What are the 10 Core Chronic Diseased that is eligible for Medicare Part D?

1. Alzheimer's Disease

2. Bone Disease-Arthritis (osteoporosis, osteoarthritis, or rheumatoid arthritis)

3. Chronic Heart Failure (CHF)

4. Diabetes

5. Dyslipidemia

6. End Stage Renal Disease (ESRD)

7. HIV/AIDS

8. Hypertension

9. Mental Health Diseases (depression, schizophrenia, bipolar disorder, or chronic or disabling disorders)

10. Respiratory Disease (asthma, COPD, chronic lung disorders)

how is one enrolled in Medicare Part D?

• Automatic enrollment

--> "Opt-out" method of enrollment only

• Beneficiaries targeted on at least a quarterly basis

• Data sources: drug claims, medical claims, patient information, + health assessments

what are the required MTM services under Medicare Part D?

- Annual CMR with written summaries in CMS standardized format that may result in recommended medication action plan

--> Face-to-face, Phone, or Telehealth

--> Patient or Caregiver

- Quarterly TMRs with follow-up interventions (when necessary)

- Interventions for both beneficiaries and prescribers

- Info about safe disposal of prescription drugs that are controlled substances, drug take back programs, in-home disposal and cost-effective means to safely dispose of such drugs

What are the MTM core elements?

- Comprehensive Medication Review (CMR) or Medication therapy review(MTR)

- Personal medication list (PML)

- Medication action plan (MAP)

-Intervention and/or referral

- Documentation + follow-up

what is a comprehensive medication review (CMR)?

A systematic process of:

- Collecting patient-specific information

- Assessing medication therapies to identify drug-related problems

- Developing a prioritized list of drug-related problems

- Creating a plan to resolve them

The CMR may be comprehensive or __________

targeted

what is a Personal Medication List (PML)?

- record of the patient's medications (prescription and nonprescription, herbals, and dietary supplements)

- Patient receives PML completed by the patient with the assistance of the pharmacist or by the pharmacist

- Written at appropriate literacy level

- In institutional settings, the PML may be created at discharge from the patient's chart or medication record

what may the PML include?

- Patient demographics

- Emergency contact information

- Primary care physician (name and phone number)

- Pharmacy/pharmacist (name and phone number)

- Allergies and other medication-related problems

- Date last updated and date last reviewed by health care provider

- For each medication, include name, dose, indication, instructions, start date, stop date, ordering physician information, and special instructions

when should patients carry the PML?

pt should be educated to carry the PML with them at all times + share it at all health care visits

what is a Medication-Related Action Plan (MAP)?

- Patient-centric document containing a list of actions for the pt to use in tracking progress

- Collaborative effort between the patient and pharmacist

- Includes only elements that the patient can act on + that are w/in the pharmacist's scope of practice or the collaborate practice agreement

- Pt should use the MAP as a guide to track progress toward a specified goal, reinforcing patient empowerment to participate in medication management

Intervention or Referral may be advised when...

- pt exhibits problems discovered during the CMR that may necessitate referral for evaluation and diagnosis

- pt may require disease state management education to help manage chronic diseases

- pt may require monitoring for high-risk medications

what type of outcomes does documentation provide?

clinical, economic, and humanistic outcomes

what are potential factors to address for MTM member enrollment?

- Costs

- Missed work days

- Disease states and potential therapy optimization

what is the most beneficial service of MTM?

Comprehensive Medication Review (CMR)

what are perspectives of the patient?

MTM Awareness

• 60-93% unfamiliar with MTM

• 70% don't think they need the service

Dispensing Perspective

• Pharmacist fills my medication "quick", "fast", "correct"

Betraying PCP

• Don't want to overstep PCP plan or have contradictory recommendations

Time Consuming

• Don't want to waste pharmacist time

Location/Privacy

• Preference varies of inside usual pharmacy vs. phone interventions

what are the perspectives of the pharmacist?

Billing Methods

- Variable fee structures, low compensation

- Plans may have requirements for providers (i.e. additional training)

Time

- Schedule busy all day (dispensing, other patient care services)

- Combines with thought with compensation

Documentation

- Paperwork may varyConfidence in skill set to document related problems

Staffing

- Feel understaffed as a pharmacist

- Technician staffing may impact ability to complete MTM services

Patient Completion

- Refuse or don't answer if being called

- Miss or cancel MTM appointment

Access to Medical Information

- Lack data - PMH, labs, other pertinent information

- Relationship with Prescribers (on-site vs. off-site)

what are perspectives of the physician?

Administrative Burden

• Increase workload

• Less reimbursement

• Less patient care

• Burnout

Patient Health Overall

Professional Roles

what do the SPO and ECHO models stand for?

SPO

• structure-process-outcome

ECHO

• economic-clinical-humanistic-outcome

Describe the SPO model:

Structure describes:

- Characteristics of providers

- Tools and resources available

- Physical or organizational settings in which they work

Process describes:

- Set of activities that occur between patient and provider

- Includes the services we provide and the manner in which these services are provided

- Technical or interpersonal

Outcomes describes:

- The effects of care on the health status of patients/populations

- Can be intermediate or long-term

- Key indicator of service quality

Describe the ECHO model:

Economic

- Costs + Utilization

- Actual vs.Estimated costs

- Direct + Indirect costs

Clinical

- Disease state changes

- Lab values

- Adverse drug events

Humanistic

- Patient reported outcomes

- Receive from surveys/interviews

Outcomes

- End Result

Pharmacy Quality Alliance (PQA)

• Coordinate efforts to develop pharmacy specific quality measures

• Majority owner of Pharmacy Quality Solutions (PQS)

National Committee for Quality Assurance

Works to improve the quality of healthcare overall

Centers for Medicaid and Medicare Services (CMS)

Works with NCQA & PQA to include performance objectives in MedicareAdvantage and Medicare Part D Plans

Center for Pharmacy Practice Accreditation (CPPA)

Focused on community pharmacy quality

what is Medicare Plan Rating (Star Ratings)?

- Provides beneficiaries info on a plan's quality and performance (1-5 stars assigned by CMS)

- Higher ratings reward the Medicare plan; Lower ratings may remove plans or apply sanctions

how is YOUR pharmacy impacted by Medicare Star Ratings?

- Pharmacy has the potential to impact up to 50% of Medicare PDP's overall star rating

- Plans want to contract with pharmacies that will help them achieve high quality ratings

- Your pharmacy could be Preferred, Non-preferred, or excluded on Medicare Plans

- Changes in prescription reimbursement and DIR fees

EQuIPP®

Program developed by Pharmacy Quality Solutions (PQS) that provides benchmarks for performance measurements + compares your pharmacy's data

Star Rating

NOT the same as a CMS Star Rating. This is generated by EQuIPP or Outcomes MTM to share with PDPs

2024 Performance Measures

• Diabetes medication adherence

• Hypertension medication (RAS antagonists) adherence

• Cholesterol medication (statin) adherence

• CMR Completion Rate

• Statin Use in patients with diabetes

What value do MTM's hold?

-Increased professional satisfaction

- Revenue generation

- Building connections with patients

- Increased quality/performance measure

- Reduced medical/total health care costs

Where do Medication Reviews occur?

Hospital Admission

--> Detect DRPs and ensure appropriate therapy

Transitions of Care

--> Identify accurate medication lists between care levels an/or facilities

Hospital Discharge

--> Identify accurate list to out patient facilities or patient's formulary

Office Visits

--> Physicians, nurses, pharmacists

Local Pharmacist

--> Completed in accordance with patients' PDPs

what should be observed/done Pre-CMR?

Medication List

- Rx claims (pharmacy, EHRs, etc.)

Disease States

- ICD codes

- EHR

- Medication reasoning

- Labs

Healthcare providers

- Physicians, NPs, PAs

- Specialty, address, Phone & Fax #'s

Identify Potential Medication Related Problems

MRP List vs. Patient Problem List

- Overall problems may have more than one solution (diet, exercise, medications) and be more generalized (diabetes, asthma, depressions, etc.)

- MRPs are specific to a medication that may impact the overall patient problems

what are the components of the intro of the MTM session?

1. Address the patient in respectful manner

2. Introduce yourself professionally (name, title/role)

3. Purpose of the session

4. Subject to be covered

5. Outcome(s) of the session

6. Confidentiality

7. Amount of time needed

what should you include in PML during MTM session?

• Include prescriptions, OTC products, vitamins, minerals, herbals, supplements

• Confirm medication name (brand/generic), strength, dosage form, directions, indication, prescriber

• Ask questions in a way to assess their knowledge

• Adherence

T or F, generating a MAP is a collaborative effort with the patient

true

what should you include in follow-up during MTM session?

- Purpose of the follow-up

- Day of follow-up

- Time of follow-up

- Contact Method

- Your Contact Information

what should be done post-CMR?

• Document session

- MRPs

- PML

- MAP

- Follow-up

• Prescriber Communication

how much eye contact should you give when talking to the patient?

50-75%

what type of questions should be avoided when communicating with a patient?

Leading/loaded questions... they guide patient towards certain answers

what are examples of active listening?

- Repeating: State something back to the patient they already told you or key phrases they used

– Paraphrasing: Interpret what you heard and repeat back to the patient

– Summarizing: Communicate the main points back to the patient

what are examples of reflective listening?

- Acknowledge the emotions behind patient responses

- Express empathy

what are sensitive subjects that may arise during communication?

Substance Abuse

– Utilize resources available through SAMHSA, WHO, NIAAA, etc.

Weight Loss

– Ask about preferred weight, what has worked previously, their next steps

Sexual Health

– Medications, side effects, QOL

what does SBAR stand for?

S: Situation

B: Background

A: Assessment

R: Recommendation

why is documentation important?

- permanent record... if you didn't document it, it didn't happen

- for performance measures

- laws & regulation

- finances, billing, insurance audit purposes

- EHRs

what does the PPACA (Patient Protection and Affordable Care Act) state?

states pharmacists should document and communicate information to other health care providers in a timely fashion

what are some barriers to proper documentation?

- Access to healthcare records

- Inconsistent methods/templates by pharmacists

- Multiple healthcare networks may use different software

- Time consuming

- Pharmacists not recognized as eligible providers in the EHR

- Training

- Liability

what challenge does documentation with technology introduce?

the challenge of the "Third Party"

what are the 5 C's of Risk Management Practice?

Correct

- Most errors in recordkeeping + communicating result from failure to accurately convey information

Complete

- Include ALL information that is needed to provide comprehensive care for the patient

Concise

- Be efficient with your words. Wordy responses may be misinterpreted or trigger suspicion/blame

Consistent

- Keep your pattern of comments the same. If it changes, it maybe misinterpreted

Cautious

- Carelessness of word choice may also cause others to misinterpret

why is following up with the patient important?

• Comprehensive Care

- Pharmacists' Patient-Care Process

• Evaluate Safety + Efficacy

• Collaboration/Trust with patient + healthcare providers

CMR vs TMR

SMART goals

Specific, Measurable, Attainable, Realistic, Timely

what/who are the different types of payers?

- Private pay (patient, family caregiver)

- Health Insurance

- Patient-centered medical homes

- Accountable-care organizations

- Medicare Part D

- Government health agencies

- Employer-based programs

- Retirement programs

- Self-insured companies

- Indigent health plans

- 340B prescription programs

- Charitable programs

what are the AMA Current Procedural Terminology (CPT) codes?

master set of medical billing codes, descriptions, + guidelines for services + procedures

What are the different categories of CPT codes?

• Category 1 - Primary codes

• Category 2 - Supplemental tracking and performance measurement codes

• Category 3 - Temporary or emerging technology

what do CPT advisors do?

• Participate by providing input and guidance on healthcare billing

• Review/update CPT codebook annually

how can CPT codes be submitted?

electronically or manually

what form is used for outpatient?

CMS - 1500

what form is used for inpatient?

CMS - 1450

what is a superbill?

• Common services & codes your practice may use

• Internal used with billing/accounting staff

• Can be given to patients as well

what pharmacist codes are used in MTM services?

99605, 99606, 99607

99605

New patient, initial encounter provided face-to-face up to 15 minutes

99606

Established patient, initial encounter provided face-to-face up to 15 minutes

99607

Each additional 15 minutes added onto initial encounters (new or established)

what pharmacist codes are used in office - "incident to"?

99211, 99212, 99213, 99214, 99215

what is the purpose of the pharmacist codes used in office - "incident to"?

• Providing patient care services in conjunction with a physician(primary)

• Primary provider is supervising or available for assistance

• Increasing intensity or level of care (time, details, complexity)

what are the pharmacist codes used in Chronic Care Management (CCM)?

99490, 99487, 99489

99490

- At least 20 minutes of time is spent on care management activities

--> Multiple (≥2) chronic conditions expected to last at least 12 months or until the death of the patient

--> Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

--> Comprehensive care plan established, implemented, revised, or monitored

99487

Same as 99490 + moderate/high complexity and minimum of 60 minutes/month

99489

Additional code for complex patients for each additional 30 minutes/month

what are transitions of care?

- Focused on improving coordination of care during periods of transition (Inpatient to outpatient)

- 1 Face to face visit + remote services

- Must have communication about appointment within 2 business days of discharge

- Available 29 days post-discharge for 1 provider

- Collect and review discharge information, determine/coordinate follow-up needs, interaction with other providers, education, coordinate referrals

what are the pharmacist codes used for transitions of care (TOC)?

99495 and 99496

99495

moderate complexity, visit completed w/in 14 days

99496

high complexity, visit completed w/in 7 days

what are the pharmacist codes used in Telehealth?

99441, 99442, 99443, 98966, 98967, 98968

99441

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

99442

11-20 minutes of medical discussion

99443

21-30 minutes of medical discussion

98966

Telephone evaluation and management service 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 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967

11-20 minutes

98968

21-30 minutes

what are the codes used during annual wellness visits (AWV)?

G0438 and G0439

G0438

initial AWV visit, once/lifetime

G0439

subsequent AWV, and annual visits

what are the diabetes self-management training (x30min) codes?

G0108 (individual) and G0109 (group)

what are the diabetes education (x30min) codes?

• 98960 (individual)

• 98961 (2-4 patients)

• 98962 (5-8 patients)

what does the Relative Value Scale (RVS) Update Committee do? who gives them this authority?

- performs the financial survey to determine the value range of the code

- CMS gives this authority

How is code value determined?

- Determine estimate of professional time, support staff time, overhead, liability, and resources to perform the specific code

- May vary based on geographical region

- Cost Analysis is crucial

--> Determine all costs involved, breakeven points, cost margin, etc.

Codes not used for Medicare Part B services need to be surveyed by...

their own organization to determine market value (various algorithms available)

If not covered, then the reimbursement method would be ____________

"private pay"

Codes allow a way for _________ to be involved in billing

pharmacists

T or F, CMS pays specifically for pharmacist services

false, CMS does not pay specifically for pharmacist service...

--> lack of Provider Status

what are the geriatric syndromes?

falling, confusion, syncope, weight loss, urinary incontinence, dizziness, etc.

what is frailty?

Unintentional weight loss >10 lbs in 12 months, physical exhaustion, weakness in grip strength, declined walking speed, low physical activity