Managing a Clinical Practice

Mary Ann Kliethermes, Pharm.D.

Midwestern University
Downers Grove, Illinois
 Managing a Clinical Practice

Managing a Clinical Practice

Mary Ann Kliethermes, Pharm.D.
Midwestern University
Downers Grove, Illinois

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Learning Objectives scorecard. Which of the following group of orga-

nizational measures reflects a balanced scorecard?
1. List three critical clinic functions for your clinic to A. Percent of providers trained in correct blood
assess and review on an annual basis to sustain a pressure measurement, percent of patients
top-level practice. with blood pressure values documented at each
2. Develop a robust quality assessment program for visit, percent of blood pressure values less than
your clinical service using the balanced scorecard. 140/90 mm Hg, performance reimbursement
3. Analyze sources of quality measures important to for meeting blood pressure value goals.
your organization, and select the measures impor- B. Errors made in computerized provider order
tant to your practice site or patient population. entry (CPOE) system, patient satisfaction
4. Develop a credentialing and privileging process to scores, hospital readmissions for heart failure,
ensure the competency of pharmacists providing weight documentation in chart.
direct patient care in your clinic setting. C. Number of faxes versus electronic medical
5. Differentiate pharmacist billing opportunities record (EMR) use for lab communication,
between a hospital-based clinic, physician office, HgA1c values less than 8, adherence rates to
and community pharmacy. oral diabetic medications, number of diabetes
6. Develop a proposal for pharmacists at your clinic visits per month per patient.
site to participate in the range of current Medicare D. “Incident to” evaluation and management code
billing opportunities that will sustain the service for revenue, number of referrals for smoking ces-
the next several years. sation, documentation of smoking cessation
7. Describe how pharmacist services in your setting education, maintenance of Board Certified
may be incorporated into the Medicare Part B Ambulatory Care Pharmacist (BCACP)
Quality Payment Program. credentials.

3. Your organization is moving toward value-based

Self-Assessment Questions payment models. It recently has become a Medicare
Answers and explanations to these questions can be shared saving organization. To sustain your services
found at the end of the chapter. within the organization you want to make sure you
are contributing the quality measure set for this
1. Critical to a well-functioning clinic is for your work Medicare payment model. Which of the following
flow to be efficient and to seamlessly integrate with measure sets should you review?
that of other team members. Evidence is building on
A. Healthcare Effectiveness Data and Information
how to develop optimal work flow in primary care
Set (HEDIS) measures.
practice. Which of the following is a strategy that
B. Physician Quality Reporting System (PQRS)
improves clinic work flow?
measures.
A. Strict adherence to policy and procedures. C. Meaningful use measures.
B. Develop a previsit planning program. D. Accountable care organization (ACO) measures.
C. Invest in technology and provider alerts.
D. Set a consistent time frame for patient visits. 4. Your practice is growing and in need of hiring
another pharmacist practitioner. Your physician
2. There are three dimensions of quality in health care: partners have clearly stated that they desire the same
structure, process, and outcome. Optimal patient level of skills from the new hire that you have in
outcomes of your services are important to mea- order for them to be comfortable in extending the
sure, in particular for those entities outside your collaborative practice agreement to that person. Risk
team. Internally, however, it is difficult to produce management is also concerned with consistency and
the desired outcomes without paying attention to a a same standard of practice and skill. To mimic what
term used in business management: the balanced is used by the organization to higher physicians,
nurse practitioners, and physician assistants, you

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develop a competency and privileging program for is a recognized National Committee for Quality
patient care pharmacists. Which of the following is Assurance (NCQA) medical home. You want to
the best tactic to use to provide assurance to your make sure your services continue to be considered
organization that the best hire has been made? valuable as the practice prepares for adapting to
A. BCACP credentials. MACRA rules for its Medicare patients. Which of
B. Postgraduate year two (PGY-2) training. the following is the best course of action for you to
C. Peer review of services at 90 days. consider?
D. Medication therapy management (MTM) train- A. Recommend that when choosing from among
ing certification. the required six core measures, the practice
include one that your service has contributed
5. You are a pharmacy director of a community hospi- to above-average reporting in the PQRS for the
tal that lost 3% of its Medicare revenue this past year medical group.
because of the readmission penalty. To rectify this B. Development of patient decision aids for heart
problem, the hospital has a strategic plan to improve failure.
their ambulatory care presence. You have pharma- C. Integrating more pharmacists into the practice,
cists currently in the ambulatory clinic attached to because this is included in the proposed options
the hospital, but you have not pursued billing for for the practice improvement portion of the
their services. You believe the current pharmacists’ reimbursement.
services meet well the intent of the new strategic D. Developing an information exchange with
plan, but you also know revenue generation ability a community pharmacy for better patient
will be a key component in sustaining these ser- coordination.
vices. Which of the following code sets will be most
beneficial for you to pursue in sustaining and even
growing these services?
A. 99605–99607 MTM service codes.
B. 99211–99215 “incident to” evaluation and
management (E/M) codes
C. Ambulatory Payment Classification (APC)
5012, G0463 facility fee codes.
D. APC 5011, Current Procedural Terminology
(CPT) 99490 Chronic Care Management codes.

6. Which of the following billing opportunities may a

physician group use to generate revenue for patient
services performed by pharmacists under general
supervision?
A. MTM codes.
B. CCM codes.
C. “Incident to” codes.
D. Wellness visits.

7. It is anticipated that the majority of Medicare Part B

providers under MACRA will not qualify to partici-
pate in the Advanced Alternative Payment Model
(APM) program and will be required to partici-
pate in the Merit-Based Incentive Payment System
(MIPS). You currently run a heart failure pharma-
cist-based service for a large medical practice that

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Summary of Case Examples

1. You have completed 1 year of services in the health-system outpatient clinic with primary care and medical
specialty services. The initial purpose of your clinic was to assist in the management of patients with heart
failure and chronic obstructive pulmonary disease (COPD) after hospital discharge with the goal of reduc-
ing 30-day readmissions. You currently are analyzing the results of the impact of your service on 30-day
readmissions. Your services have been well received within your organization, and you currently enjoy a
well-established practice. Your practice has grown significantly, including other patient referral types, partic-
ularly patients with diabetes in need of better disease control and education. Recently, however, it has become
increasingly difficult to schedule patients with COPD and heart failure within the 72 hours post-discharge
goal because of your patient volume.

2. The community pharmacy chain for which you manage clinical services is now 6 months into a contract with
the local physician group. Stipulated in the contract is a formal review of services provided at 6 months. The
6-month review will primarily address processes. Another report focusing on quality measures and patient
outcomes is due at 12 months. A lack of optimal communication processes has emerged as an important bar-
rier to efficiency in services.

3. You are a co-funded ambulatory practice assistant professor with a practice site at a family practice office.
You have been providing clinical services to this office for 1 year. You have had students and residents at the
site. The practice is pleased with the clinical pharmacy services and now wants to explore billing opportuni-
ties and increase your responsibility in contributing to their value based payments, including HEDIS for their
commercial payers and the Quality Payment Program for Medicare Part B. The practice is recognizing the
value of your services and would like to discuss expanding the scope of what you provide to the practice.

With an established practice, the focus will shift to maintaining and growing a successful clinical service. Similar to
starting a service, there are key activities that you will need to pay attention to simultaneously.

I. GENERAL ONGOING MANAGEMENT (Domain 4, Task 4)

A. Maintaining Policy and Procedures. Despite careful planning and good intentions, some processes will not
work as well as envisioned. Policies and procedures are guides that provide a level of standardization and
quality for your program. If issues are identified in the early stages of implementation, address and revise
them as they occur.
1. Review policy and procedures yearly. Doing so will keep the review process manageable. Waiting too
long will result in outdated policies that may require a major overhaul, often resulting in a large workload
for you and your staff.
2. Assign the reviewing responsibility to the staff members who perform the functions in the policies.
Because they perform the process daily, they will be able to detect discrepancies or needed policy and
procedure changes.

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B. Maintain your practice to Meet the Minimum Current Standards of a Pharmacist Ambulatory Care Practice.
Current minimum standards of patient care in ambulatory care are described in the following references: Am
J Health Syst Pharm 2015;72:1221-36; Council on Credentialing in Pharmacy Credentialing and privileging
of pharmacists: A resource paper from the Council on Credentialing in Pharmacy. AJHP 2014; U.S. Public
Health Service 2013; American Pharmacists Association and National Association of Chain Drug Stores
Foundation 2008; Patient-Centered Primary Care Collaborative 2012; ACCP Standards of practice for
clinical pharmacists. Pharmacotherapy 2014;34:794-7; and Joint Commission of Pharmacy Practitioners
Pharmacist Patient Care Process 2014.
1. Collect: Gathering patient information from the medical record and interviewing patients or caregivers
to obtain pertinent information needed for patient care
2. Assess: Assessing the legal and clinical appropriateness of the medication regimen to identify, resolve,
and prevent medication-related problems
3. Plan: Participate with health care team members and the patient in medication and disease-state therapy
decision-making and development of patient goals and plans of care.
4. Implement: Initiate the plan, including educating patients and caregivers on disease, medication therapy,
adherence, and preventive health
5. Follow up, monitor, and evaluate: Monitoring the effect of medication therapy on patient health outcomes
6. Documenting and communicating services provided, as well as creating and maintaining medication
profiles, medication-related plans of care, and other needed patient care documentation

C. Stay Up to Date. Health care and practice is dynamic and constantly changing. Find effective processes for
staying abreast of current practice. Pay particular attention to the following areas:
1. Pharmacy practice and therapeutic literature
a. Pharmacy and other appropriate practice organizations are valuable ways to stay abreast of practice
changes and trends.
i. Regularly review respective journals, reports, and web-based resources such as table of contents
and e-mailed news briefings.
ii. Become involved with at least one professional organization in some manner.
b. Therapeutic literature
i. Medical journals pertinent to your practice (e.g., primary care, general internal medicine,
diabetes, cardiology)
ii. Guidelines. These are often published in the respective specialty medical journals. However,
the website for the National Guideline Clearinghouse is no longer supported by the federal
government as of July 2018. The subcontracted organization, the ECRI Institute, which is an
independent, nonprofit patient safety organization that maintained the site under AHRQ, has
created a similar resource called the ECRI Guidelines Trust. The site supported by ECRI
Institute is a website for evidence-based guideline briefs and scorecards. The healthcare
community has free access to the website at guidelines.ecri.org.
2. Laws and regulations: In today’s environment, health care laws, rules, and regulations change often to
adjust to the dramatic changes occurring in health care structure and payment.
a. State board of pharmacy. Review state laws and the rules and regulations for pharmacy practice.
With the potential for provider status and federal rules to dictate that the services provided must
be within the state scope of practice, it is more important than ever that your state practice act
completely cover the scope of services you are providing. Currently, there is wide variability in
scope of practice among the state pharmacy practice acts.
b. State government and state health care provider practice acts. Laws that may change, affecting
practice and state-sponsored health insurance plans (e.g., Medicaid, third-party payers)

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c. Federal government
i. U.S. Food and Drug Administration (FDA). Approves new medications and issues warnings or
other recommendations for already-approved medications
ii. U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid
Services (CMS). Determines the rules and regulations for federally sponsored health care plans.
Many of the rules and regulations for Medicare are updated yearly.
iii. Centers for Disease Control and Prevention (CDC). Determines the rules and standard
procedures for point-of-care testing, immunizations, and management of patients with
transmittable diseases
iv. Protection of patient information (Health Insurance Portability and Accountability Act
[HIPAA]). It is important to ensure that your processes in patient care and exchange of
information comply with HIPAA.
d. Other organizations
i. Occupational Safety and Health Administration (OSHA) guidelines. OSHA guidelines are
particularly important if you are handling medications or other potentially hazardous materials.
ii. Accreditation organizations. Establish standards for quality and safety. An accredited practice is
often required by payers for contractual relationships and/or payment. What has been common
in the institutional setting is becoming increasingly common in the ambulatory setting with the
various types of standards supported by the organizations listed.
(a) Joint Commission
(b) National Committee for Quality Assurance (NCQA) Patient Centered Medical Home
(PCMH) recognition
(c) Center for Pharmacy Practice Accreditation (CPPA)
(d) URAC

D. Update and Review Your Collaborative Practice Agreement on a yearly basis or as dictated by state laws,
rules, and regulations.

Practice Case 1

You are pleased to be receiving referrals for patients with diabetes in your clinic because this area of practice has
always been a strong interest of yours. However, these referrals are slowing you down in the clinic because you do
not have a collaborative practice agreement established for diabetes management. In addition, patients are calling
your service instead of their medical providers for refills of medications, which was not included in your original
collaborative practice. For the yearly review of the program with the medical group physicians and administra-
tors, you request that these issues be placed on the agenda. During the meeting, it was agreed to add authorization
of refills to the collaborative practice agreement. An endocrinologist will be recruited to review your service, and
you will work with that physician to develop a diabetes management collaborative agreement.

This case demonstrates a real situation in showing how much can change in 1 year. Therefore, it is good practice
to set up a standard annual review of the documents that guide your daily practice.

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II. MAINTAINING AN EFFECTIVE TEAM AND FUNCTIONING AS AN EFFECTIVE HEALTH

CARE TEAM MEMBER (Domain 2 Task 7)

The Institute for Health Improvement (IHI) triple aim of improving patients’ experience of care (i.e., satisfaction
and outcomes), reducing the cost of care, and improving population health has been the driver of the dramatic
change in health care we have witnessed in the past few years. The success of the triple aim is dependent on
health care being delivered by teams of health care providers composed of many disciplines versus sole individual
providers. The complexity of health care demands team-based care. However, systems of care, work flow, infor-
mation technology and means of communication have not kept pace with the needs and demands of team-based
care. Your sustainability will rest on your ability to overcome these barriers by understanding features of effective
teams and establishing standard reliable methods for work flow, communication, and documentation.

A. Features of effective teams. Weller, et al., reviewed extensive research in team performance from across a
range of industries and adapted the identified best models and their respective features to health care team
functioning. They are as follows:
1. Team leadership. Team leaders coordinate tasks of team members, plan daily work, are concerned with
team member development, motivation, and establishing a positive atmosphere. Team leaders are usually
physicians.
2. Mutual performance monitoring. Team members all require sufficient understanding of the environment
within the workplace in order to monitor other team members such that any member is able to step in
and assist when task overload or lapses are identified.
3. Backup behavior. Team members have sufficient understanding of others’ tasks to enable effective
redistribution of workload or needed support with the variances in service demand.
4. Adaptability. Adaptability enables the team to respond to changes in environment in order to change
patient management and work flow as needed to maintain patient care and the desired outcomes.
5. Team orientation. Willingness to take others’ ideas and perspectives into account and a belief that team
goals should be aligned with what is best for the patient, e.g., patient centeredness.

B. Characteristics of effective teams. Ambulatory pharmacists should strive to model these characteristics.
1. Respect and trust in order to give and receive feedback on performance
2. Good communication skills to accurately convey information
3. Shared mental model defined as a common understanding of the situation, plan of care, roles, and tasks
of individuals on the team. Weller describes this as being “on the same page.”

C. Work flow. Your goal for success and sustainability is to be a high-performing clinic in a high-performing
organization. The provision of health care and its subset of medication management and optimization are
complex adaptive systems (CAS). A CAS is defined as a group of diverse individuals who learn together (e.g.,
learn about a patient) and is defined by interdependent connections that vary in intensity and may be inconsistent.
In CAS the cause and effect is not necessarily linear. For example, you may provide optimal patient care that
you expect would achieve a desired outcome. However, because health care is a CAS, there are other influences
such as other providers, the social environment, and the patients themselves, that may influence positively or
negatively the desired outcome. Patients’ conditions, evidence for treatment, and system complexity contribute
to the intensity and inconsistency that is inherent in health care and optimizing medications.
1. Recommendations for optimally working in a CAS. Ambulatory pharmacists should strive to model
these recommendations.
a. Mindfulness: Mindfulness is an awareness of the current system and how coworkers and team
members think, work, and respond.

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b. Processes should allow for inherent variability so that care providers can quickly recover for
unexpected occurrences and navigate the variability efficiently. Create standard work flow and
communication processes that allow fluidity and a constant attention to trouble spots in order to
set a culture for quick reworking and improvement. Learning and continuous problem-solving are
vital to managing complexity. Three levers for managing complexity are proposed by Provost, et al.
i. Conversation. Do not limit interactions to just information exchange; move to problem-solving
and problem dissolving which means to, if possible, remove the root cause of the problem so it
does not occur again.
ii. Relationships. Eliminate variation in training and status in the team because these differences
limit conversations and the development of shared understanding and learning
iii. Culture. Create an environment in which learning and action occur together and which does not
need a hierarchy or excessive time to improve a problem.
2. Work flow as defined by Unertl, et al., is a dynamic construct that includes three pervasive elements:
a. Temporality
b. Aggregation of actors and actions
c. Context that constrains and enables actions
3. Address areas variability in ambulatory clinic work flow. Focus on building resiliency and efficiency and
avoiding unnecessary stress points.
a. Staffing
b. Clinic pace
c. Technology use during visits
d. Computer access
e. Access to clinical data
4. Evaluate the pharmacist work flow in your clinic routinely. Allow for variation in work flow and sequence
as individual patients’ agendas, needs, and characteristics have a significant role in the process. When
variability is not accounted for, the result is reduced productivity, increased chances of error, and other
potentially negative outcomes.
a. Use the Joint Commission of Pharmacy Practitioners (JCPP) standard patient care process as foundation
for your work flow (presented in the Process of Care/Organizational Agreements/Special Issues in
Practice Management chapter).
b. Consider using the document “Workflow of Pharmacist Clinical Documentation Process in Pharmacy
Practice Settings” as a resource, available from the Pharmacy Health Information Technology
Collaborative. www.pharmacyhit.org/pdfs/workshop-documents/WG3-Post-2014-03.pdf
5. Evaluate patient flow through your system regularly.
a. Collect required patient information once if possible.
b. Minimize how often a patient is moved. Emerging evidence suggests that moving providers is more
efficient.
c. Use evidence-based practices in the treatment and monitoring of medical conditions to reduce any
disagreements in management within the team.
d. Eliminate unneeded or excessive activities.
e. Eliminate any duplicative communication whenever possible.
f. Provided concise and clear information to the patient.
6. Data are emerging on ambulatory care pharmacist work flow. A 2018 commentary by Smith provides
a summary, guidance, and recommendations for pharmacist staffing ratios in primary care teams. Two
recent publications provide data on assessing and evaluating pharmacist patient care work flow in the
clinic setting. Investigators evaluating workload data accumulated from the Collaboration Among
Pharmacists & Physicians to Improve Outcomes Now (CAPTION) trial found that pharmacists in this
trial spent around 33 minutes per patient in a face-to-face visit during initial encounters and 28 minutes,
on average, for face-to-face follow-up visits. The average time spent on pre visit work was 4.05 minutes

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and on post visit activities, 8.85 minutes. At the Mayo Clinic, study investigators modified a nursing tool
to track productivity and time management for pharmacists providing medication therapy management
(MTM) services integrated into the health system’s ambulatory setting. They found that pharmacists
spent 41% of their time in non visit patient care, 30% of their time in direct patient contact (70% face-to-
face time), and 30% of their time in non patient care activities such as meetings, educating health care
providers, precepting, and research. Other investigators have developed a dashboard for benchmarking
the productivity of an MTM program.
7. Joy in practice versus provider burnout. With the importance of primary care in current and future health
care reform and in care of patients with chronic diseases, it is likely that primary care will be the principle
location for pharmacist integration within team-based models. Primary care has a high prevalence of
stress and burnout for physicians. While there are no recently published studies on pharmacist burnout
in the primary care setting, similar concerns exist for pharmacists practicing in primary care, requiring
consideration of workload in managing your clinic. Several recent studies (Linzer, et al.; Sinsky, et al.)
have identified strategies to consider in clinic setup and work flow that may reduce provider burnout.
The strategies include:
a. Work flow design
i. Team and staff assignments and duties that have all members practicing at their highest skill
level. Specific strategies that may reduce lower-level skill work include:
(a) Pre visit planning
(b) Pre visit laboratory testing
(c) Sharing or splitting the documentation requirements
(d) Specific patient care delegated to team members congruent with their scopes of practice
ii. Flexible scheduling to meet ebbs and flows of patient demand (see Institute of Medicine Report
“Transforming Health Care Scheduling and Access: Getting to Now” at www.nationalacademies.
org/hmd/Reports/2015/Transforming-Health-Care-Scheduling-and-Access.aspx)
b. Improve communication:
i. Between internal providers and staff. Evidence is building supporting the use of team huddles
and meetings that are both spontaneous and planned.
ii. Between patients and clinic providers and staff, through technology like patient portals and texting
iii. Between external providers and clinic providers and staff and through participation in local and
state health information exchanges
c. Quality improvement projects that address concerns identified by patients and providers (see
Measuring the Quality of Your Program section later in this chapter).

D. Health Care Communication. As previously stated, strong communication processes are one of the most
vital aspects of ambulatory care. The success of the pharmacy service(s) will depend on how effectively you
communicate with patients, with your immediate health care team, and with all the individuals involved in a
patient’s care. Setting up standard communications processes and structures that allow needed flexibility will
help create efficiency in the program. Communication must occur bidirectionally between all members of the
health care team and strive to be conversational versus solely information exchange.
1. Methods of communication to consider. Note that team huddles or meetings have the highest number
of benefits because they most embody the team-based care concept. Team huddles are quick meetings
(synonymous with a sports team huddle) in which the team discusses patient cases and clinic organization
and develops a plan of care. This simple communication method is a cornerstone in the functioning of
integrated models of care such as the medical home. Frequency of team huddles depends on the needs
of the team. Team huddles may often occur at the beginning or end of the day and last 15 to 30 minutes,
but there are no fast rules.

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Table 1. Methods of Communication

Type Benefits Barriers
• Allows conversation and building of
relationships • May be inefficient and disrupt clinic or patient
• Allows body language interpretation flow
Face-to-face
• Immediate answer is usually provided • Works only if you are physically located near
• There exists an ability to elaborate and other providers
have in-depth discussions as needed
• May be able to receive immediate answer • Connecting with person may be difficult
• There exists an ability to elaborate, • May be intrusive
Telephone or although less so for conversation and • If unable to reach the person or need to use
page in-depth discussions voicemail, this may negate the benefit of person-
• May still be collegial because remains to-person contact
person-to-person contact
• Confidentiality issues; fax may go to wrong place
• Loss of collegial aspect with personal interaction
• No elaboration or discussion possible
• Record of communication
Fax and • Misinterpretation may occur because of the need
• Nonintrusive
voicemail for brevity
• Requires additional effort to scan or document in
the electronic medical record (EMR)
• Delay in response
• May not be secure or private
• Loss of collegial aspect with personal interaction
• Record of communication
• No elaboration or discussion possible
Electronic • May be nonintrusive
• Misinterpretation may occur.
messaging • Easy and convenient
• Delay in response; however, may be less delayed
• No intermediaries needed
than other methods because
of convenience
• Accessible to all providers; aids • Unable to discuss an issue
efficiency • Communication is permanent and therefore not
EMR • Written record of communication amenable to an off-the-record type of consultation
• No confidentiality issues • Without direct notification, others may not be read
• Loss of collegial aspect with personal interaction
•
Collegial and builds relationships
•
Allows body language interpretation
•
Immediate answer
•
Ability to elaborate and have in-depth • Optimal for team members to be in the same
discussion as needed location
Team huddles
• Efficient • Balance between time needed for huddles and a
or meetings
• No confidentiality issues busy workload; knowing how to perform a huddle
• Allows interdisciplinary perspective is key so that the value is apparent
when addressing patient needs
(e.g., primary care physician, pharmacist,
nutritionist, behaviorist)

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2. Tools for effective communication regarding patients

a. Patient plan of care – One plan shared by all providers caring for patient
i. Everyone is working toward the same goals (including the patient).
ii. Responsibilities for action within the plan of care are clear.
b. Medication list – Should contain information other providers need and in an easy-to-use format
i. Basic patient demographics (e.g., name, date of birth, height, weight)
ii. Date prepared, preparer name, and contact information
iii. Allergies and intolerances with symptoms the patient experienced
iv. Medications listed under the conditions for which they are used
v. Medication generic name with trade name in parentheses, total dose taken, and direction for
taking it, together with how supplied, if needed, in parentheses
vi. Start dates, if known
vii. Include herbals, over-the-counter medications, and vaccinations.
viii. Prescribing providers, their specialty, and contact information
ix. A list of medications that were discontinued and reason for discontinuance
3. Continuity of care. After a patient visit, it is your responsibility to communicate the important aspects
of that visit to other providers or caregivers who need the patient information related to your visit. This
communication should include the following:
a. Updates or changes to the plan of care with the subsequent expectations and follow-up
b. Any new, pertinent patient information discovered
c. Adherence/persistence with medications
d. Drug-related problems and plans to resolve them
e. Education or advice provided

E. Internal Communication. Determine how to interact with team members caring for a mutual patient. Your
physical proximity to the other team members is critical in setting up the communication process. There is no
standard method for directly communicating within a patient’s health care team. Each situation may dictate
a preferred method, as may each provider.
1. Notify other providers of how you plan to communicate with them for routine and acute medical situations.
2. Determine a standard method for obtaining needed information from others.
a. Agency for Healthcare Research and Quality (AHRQ). Improving Medication Safety in High-Risk
Medicare Beneficiaries Toolkit (http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-
reviews-and-reports/?productid=1186&pageaction=displayproduct). Provides an easy-to-complete
one-page form that can be sent to other providers to gather key patient information you may need
to provide your services.
b. As a standard function during their rotations, pharmacy students could pull data from an EMR or
other sources.
c. EMR pharmacist documentation. Your EMR vendor can design a template in which key information
you may need will auto-populate the template from data already in the EMR.
d. Use a pharmacist-specific technology tool that fits your workload process and integrates with the EMR.
3. Determine which team members may deviate from the standard method and prefer a different means of
communication (e.g., a fax vs. a page). Keep a record of the communication process for team members
or other key providers.

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F. External Communication. All external communications are considered transitions of care. Establish standard
methods to communicate patient information between providers, organizations, and settings outside your
service and organization.
1. Information that should be communicated to the next setting should be the same as noted under continuity
of care.
a. Updates or changes to the plan of care with the subsequent expectations and follow-up
b. Any new, pertinent patient information discovered
c. Adherence to/persistence with medications
d. Drug-related problems
e. Education or advice provided
2. Hospital discharges. Quality standards have been established for transition from a hospital stay. Discharge
from a hospital is a transition that is known to have risks for significant medication-related problems.
You may wish to use this quality measure as a tool in your clinic or the guidance document by Kirwin,
et al.
a. Standards for discharge documentation based on National Quality Forum measure
i. Transition record: Patient’s diagnosis, treatment, and care plan provided to patient in printed
or electronic format and transmitted to the facility/physician/other health care professional
providing follow-up care
ii. Current medication list: All medications to be taken by patient after discharge, including all
continued and new medications
iii. Clear instructions on which medications the patient should no longer take or use and instructions
for disposal
iv. Advanced directives for medical care at end of life or when they may be unable to do so.
The transition should contain a statement of what the wishes are for the patient (e.g., do not
resuscitate).
v. Documented reason for not providing advanced care plan
vi. Contact information/plan for follow-up care
vii. Plan for follow-up care: Includes post-discharge therapy needed, any durable medical equipment
needed, and family/psychosocial resources available for patient support
viii. Primary physician or other health care professional designated for follow-up care
b. Standard 24-hour/7-day contact
c. In efforts to ensure coordination of care, you may find several individuals representing various
health care groups or providers calling a patient post-hospitalization. To avoid overburdening the
patient, be aware of others who plan to contact the patient and coordinate these efforts because too
many organizations calling a patient can be as negative as no coordination.
d. Medical office transition-of-care visit is a billable visit (addressed later in this chapter).
3. Long-term care
a. Although there has been significant work to improve transitions from hospital to long-term care,
there has been much less attention to the transition from long-term care to home. Currently this
transition is very difficult because no standards exist.
b. Often difficult to obtain information because there is no point person who can provide the
information, or that person is not readily available
c. Patients discharged with their medications in the blister packets used in the long-term care setting,
may result in duplications of some of the patient’s medications at home and is often confusing to
patients
4. Specialists and other providers: Home nursing. Home-visiting nurses may be a very useful resource
because they can assess how patients are functioning in their homes. These providers are required to
perform an extensive home assessment, which includes a list of medications found in the home.

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5. Others. In integrated models of care, such as Accountable Care Organizations (ACOs) and medical
homes, community-based workers, such as listed in the following, are part of the health care team and
may be very helpful in assisting the transitions process.
a. Case workers
b. Community health workers
c. Rehabilitation centers

III. ESTABLISH A STANDARD PROCESS FOR DOCUMENTATION (Domain 4, Task 1, Item 2)

A. Goals of Documentation. Medical care documentation must meet many goals, as listed in the following.
It is important to keep these in mind when developing your documentation templates and processes.
1. Meet professional standards and legal requirements.
2. Communicate effectively and efficiently with other health professionals.
3. Establish accountability for medication-related aspects of direct patient care.
4. Facilitate transitions and continuity of care.
5. Create a record of critical thinking and judgment.
6. Provide evidence of provider value and workload.
7. Justify reimbursement for cognitive services.
8. Provide data for tracking patient health outcomes.

B. Electronic Portals for Documentation

1. American Recovery and Reinvestment Act of 2009, or the Health Information Technology Act, has
changed the landscape for documentation, creating the meaningful use initiatives. The act incentivized
health care organizations to use electronic portals for documentation. With the passage of the Medicare
Access and CHIP Reauthorization Act (MACRA) in 2015, the meaningful use initiatives are now part of
MIPS in the Promoting Interoperability category (discussed under the Quality section of this chapter).
a. Healthcare Interoperability for exchange of information: The focus of Office of the National
Coordinator (ONC - often referred to as the health IT czar) for 2018 is on interoperability and was
legislatively mandated in the 21st Century Cures Act (Cures Act) passed in 2016, adding on to the
previous legislation. The Cures Act directs ONC to implement activities that advance interoperability
through continued work on combating information blocking and building health IT exchanges. For
more information visit: https://www.healthit.gov/topic/interoperability.
b. Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) codes will be the
standard for health information exchange. Codes that reflect documentation of the care pharmacists
provide patients in ambulatory patient care are currently being identified or under development
for SNOMED by the Pharmacy e-Health Information Technology Collaborative. This will allow
alphanumeric coding behind clinical documentation that will allow the electronic sharing of a clinical
note between different EHRs and providers. Standardization of processes will be key to enable this
activity to happen. The ONC is building pharmacist integration based on the Pharmacist Patient
Care Process (PPCP). Therefore, using the PPCP optimally in your work flow and documentation
will be critical for interoperability of your work.
2. Terminology for electronic portals for documentation
a. Electronic health record (EHR): Individual patient medical record digitalized from many locations
or sources, including patient access
b. EMR: Portal that shares relevant patient information among health professionals

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c. Personal or patient medical record (PMR): A record of health information created for or by an
individual patient
3. Feasibility of using the Electronic Medical Record (EMR) for pharmacists in the ambulatory setting
a. Often structured primarily for the physician and may not meet the documentation needs of a
pharmacist. For example, ability to pull the data from various fields in the EMR into a note template
may not exist for the particular needs of a pharmacist (e.g., data from vendor prescription refill hubs).
b. Potential access issues if working virtually or offsite
c. The EMR may not accommodate the pharmacist work process and may therefore affect the efficiency
of pharmacy work flow. For example, medication lists located at the beginning of a template may not
trigger an update of the list with changes that occur during the pharmacist’s visit.
d. A common complaint from other providers is pharmacists’ documentation is often too long and
cumbersome
4. Solutions for documentation difficulties
a. Collaborate with information technology (IT) department to determine the flexibility of the EMR
to meet pharmacists’ needs.
b. Create a work flow process and templates for IT to incorporate into the EMR.
c. Interface pharmacist documentation software into the EMR.
i. Expensive or not met with support from the organization because of integration and other IT
concerns.
ii. Pharmacist documentation software is early in development.
d. CMS Medicare evaluation and management (E/M) documentation requirements for billing Medicare
Part B (addressed later in this chapter) when using E/M codes. Documentation must state that the
service is medically reasonable and necessary and describe the work the provider performed. You
will note that the requirements are physician focused; however, when pharmacists, as auxiliary
personnel, are providing services that are billed “incident to” physicians, they must follow the E/M
requirements. The elements listed in the following must be in your documentation if you are using
E/M CPT codes (explained later in the chapter). CMS has provided an excellent resource for E/M
documentation in the Medical Learning Network: www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.

Table 2. E/M Determinants of Complexity of Decision-Making

Risk of Significant
Type of No. of Diagnoses or Amount and/or Complexity
Complications, Morbidity,
Decision-Making Management Options of Data to Be Reviewed
and/or Mortality
Straightforward Minimal Minimal or none Minimal
Low complexity Limited Limited Low
Moderate complexity Multiple Moderate Moderate
High complexity Extensive Extensive High

i. Four levels of service are used in E/M rules that denote increasing complexity (and therefore
reimbursement) should be evident in the documentation.
(a) Medical problem focused
(b) Expanded medical problem focused
(c) Detailed
(d) Comprehensive
ii. History component – Information provided should substantiate medical decision-making.
(a) Chief complaint (CC)

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(b) History of present illness (HPI)

(c) Past, family, and social history (PFSH)
(d) Review of systems (ROS)
iii. Examination: Physical examination according to body area or organ system
iv. Medical decision-making is evident by the assessment and plan of the documentation.
(a) Assessment – Includes list of diagnoses or potential diagnosis
(b) Must address the chief complaint
(c) Plan – Must list orders
v. Four levels of complexity or risk with medical decision-making. This factors into payment for
the service.
(a) Minimal
(b) Low
(c) Moderate
(d) High
vi. For 2019 CMS in efforts to reduce the documentation burden has confirmed plans to develop a
single payment rate for the office/outpatient E/M visit levels 2 through 5 (one rate for established
patients, and one rate for new patients) in 2021. CMS plans to adopt add-on codes to use when
additional resources inherent in visits for primary care and categories of specialized medical
care are required. In addition, they plan to create an ‘‘extended visit’’ code for use when
additional resources are used for necessary extended visit time with a patient. CMS will not
impose new documentation with the new codes. For now, CMS will not include level 5 visits in
the single payment rate in order to better account for the care and needs of particularly complex
patients. To start in 2021, CMS will allow flexibility in how E/M levels 2 through 5 visits are
documented. Providers will have the choice of using the current framework, MDM or time for
documentation. If the current framework or medical decision making are used, the minimum
supporting documentation standard will be that of a level 2 visit.
5. Documentation recommendations: The Patient-Centered Primary Care Collaborative (PCPCC)
Guidelines for the Practice and Documentation of Comprehensive Medication Management in the
Patient-Centered Medical Home. These recommendations have the input of experts from several
disciplines, including physicians, regarding the desired content of a pharmacist’s note.
a. Assessment of the patient’s medication-related needs
i. All medications reviewed and documented
ii. Patient medication experience is discussed and recorded.
iii. Medication history, including allergies/reactions
iv. Review and document current medications and doses; how they are actually being taken
v. Each medication assessed for indication or condition.
vi. Patient clinical status is assessed for each medication and condition for indication,
appropriateness, and effectiveness.
vii. Clinical goals of therapy for each medication
b. Identifying the patient’s medication-related problems by asking the following questions:
i. Appropriateness of the medications
ii. Appropriate for indication
iii. Is there an indication not being treated or prevented?
iv. Effectiveness of the medication
v. Is it the most effective product?
vi. Is the dose appropriate, and are the goals of therapy achievable?
vii. Safety of the medication
viii. Patient experiencing any adverse events?

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ix. Is the dose too high?

x. Adherence: Is the patient able and willing to take medication?
c. Recommended documentation framework for drug problems
i. Indication
ii. Effectiveness
iii. Safety
iv. Adherence
d. Plan of care
i. Intervention to solve problems
ii. Goals of therapy
iii. Education for self-management
iv. Outcome variables to be monitored
v. Follow-up time interval
6. Center for Pharmacy Practice Accreditation (CPPA) Community Pharmacy Practice Standards
a. Standard 1.4.1: “Systems that allow documentation into a patient record of appropriate medical/
health information: Medication list, immunizations, allergies, laboratory values, diagnoses, and
other information required to deliver patient care services”
b. Standard 2.1.1.5: “Appropriate documentation and communication of patient care to physicians and
other health care providers”
c. Standard 2.1.2: “Pharmacists deliver MTM services. … Whereby pharmacist documents the
MTM visit in the patient’s chart, including goals of therapy, care plan, interventions and referrals,
communication with other providers, in a retrievable format that is accessible to all pharmacy staff.”
7. American College of Clinical Pharmacy documentation standards of practice: “Clinical pharmacists
document directly in the patient’s medical record the medication-related assessment and plan of care
to optimize patient outcomes. This documentation should be compliant with the accepted standards for
documentation (and billing, where applicable) with the health system, health care facility, outpatient
practice, or pharmacy in which one works.”
a. Use the format of a traditional SOAP (subjective, objective, assessment, plan) note or other standard
framework.
i. Medication history
(a) Summary of medication-related health problems (i.e., symptoms, achieving goals of
therapy)
(b) Patients’ current and past medication use
ii. List of all current medications
(a) Attitudes
(b) Adherence
b. Allergies and adverse drug event history
c. Active problem list
i. Current health conditions and status of each condition, emphasizing medications and
medication-related problems
ii. Any additional medication-related problems or other medication issues unrelated to current
health conditions
d. Plan of care
i. Medication therapy plan (drug, dose, route, frequency, and relevant monitoring parameters)
ii. Plans for implementation
e. Plan for follow-up, evaluation, and future visits

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Practice Case 2

In establishing your relationship with the physician group, you decide to use current pharmacy medical office
communication processes because that was determined to be least disruptive to pharmacy operations. The MTM
referrals were sent through a computerized physician order entry process to the pharmacies for the MTM services.
The pharmacist completing the MTM services would then send a fax back to the physician office with recommen-
dations. Access to the physician group’s EMR was not provided in the original agreement because of HIPAA and
security concerns expressed by the manager of the physician group’s IT department. The agreed-on decision was
to use the patient information tool from the AHRQ MTM toolbox. The MTM pharmacist would contact the office
and ask the medical assistant to fill out that tool and submit it to the pharmacy after a referral had been established.
Process analysis identified the following concerns. The AHRQ patient information tool was not being completed in
a timely manner for the visit because of medical assistant workload. The pharmacists providing MTM noted that
it was difficult to contact physicians because each preferred his or her own method of communication (e.g., page,
faxed note, telephone call). In addition, it was difficult to keep track of the desired communication strategy because
of the many providers. The physicians stated that the SOAP notes from the pharmacists were too long and that it
was difficult to quickly identify the pharmacists’ recommendations. Moreover, different pharmacists used different
note styles. You meet with the medical director to discuss the communication barriers. Together, you develop a pro-
posal to administration that discusses the pros and cons of EMR access by pharmacy. Using the plan, do, study, act
(PDSA) cycle quality improvement process, members of the pharmacy team develop a standard template for MTM
using the PCPCC documentation recommendations. A 6-month review will be conducted to look at the timeliness
of reacting to recommendations to determine the effectiveness of this process.

Documentation and communication remain real challenges in patient care practice for pharmacists and other
providers. Since the passage of the American Recovery and Reinvestment Act in 2009, which contained the Title
XIII Health Information Technology for Economic and Clinical Health Act, and the 2016 Cures Act, much work
has occurred to use technology to improve documentation and communication at the federal and state levels. The
Pharmacy Health Information Technology Collaborative is actively involved in pharmacy’s participation in this
work, and it is important for pharmacy practitioners to stay up to date with the work and documents created from
this collaborative as well as the health information exchange processes that are federally supported and occurring
in each state.

IV. MEASURING THE QUALITY OF YOUR PROGRAM (Domain 4, Task 5; Domain 5, Tasks 1, 2, and 6)

A. Importance of Measuring the Quality of Your Services, Your Organization, and Health Care in the United
States. The movement in health care to focus on quality of care through organizational systems and payment
began with disturbing data regarding the U.S. health system’s lack of safety.
1. The Institute of Medicine (IOM) 1999 report “To Err Is Human” brought attention to the harm being
done to patients in the health system.
a. 100,000 patients die each year because of error.
b. Medications are a major source of error.
2. Quality gap in health care
a. Quality gap is the difference between top-performing organizations and average-performing
organizations.
b. In health care, the quality gap is around 20% (NCQA 2004).
c. For other “potentially dangerous” industries, such as airline travel, the quality gap is 1%.

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3. The quality ranking of the United States is around 30th in industrialized countries and consistently ranks
last when compared with the 10 top industrialized countries, yet the United States spends the most on
health care (World Health Organization 2000; Woolf 2013; JAMA 2013;310:591-608).
4. In particular, a recent large study that evaluated quality of care delivered to adults in 2002-2013 evaluated
data from the Medical Expenditure Panel Survey and found that, in the outpatient setting, improvement
in quality was mixed with some measures of quality improving, some staying the same, and some
worsening (JAMA Intern Med 2016;176:1778-90).
5. Slight improvement to no improvement, despite nearly 20 years of focus on quality in the United States.
U.S. quality rankings have remained the same.
6. High cost of health care is driving demand for the best value/cost ratio, placing emphasis on quality
measures, including the value component of the ratio.

B. Response by Payers in the Health Care System

1. U.S. government and initiation of the Triple Aim – A framework for health care improvement.
The components are as follows:
a. Better care for individuals
b. Better health for populations
c. Reducing per capita costs
2. Models of care that emphasize quality versus volume as drivers of payment
a. ACOs - An alternative payment model of integrated care delivery defined by the following elements:
i. Voluntary groups of physicians, hospitals, long-term care providers, and other health care
providers
ii. Assume responsibility for the care of a clearly defined population of beneficiaries assigned to
them by a payer(s) (e.g., Medicare), based on patients’ use of primary care services
iii. Shared savings. If the triple aim is met at better care and health with reduced costs, the savings
are shared between the ACO and the payer.
iv. Quality and quality measure reports on populations are a major part of the ACO goals.
b. PCMH – A model of primary care based on the following principles:
i. Comprehensive team-based care. Team members vary; however, they include a physician, a
nurse or nurse practitioner, and a patient coach as core members. Others include pharmacists,
dietitians, social workers, and physical and occupational therapists. Members have varied
widely and have included almost any health provider.
ii. Patient-centered or whole-person orientation
iii. Care that is coordinated
iv. Superb access to care. Ensuring that patients receive their desired care whenever they need it
v. Systems-based approach to quality and safety
vi. Payment reflective of care given

C. Alternative Payment Models. Several emerging models and terms are being used to describe the payment
models that are associated with reimbursement based on the quality of services provided and the resultant
patient outcomes.
1. Value-Based Purchasing Payment Models: Payment models and contracts for services that reward quality
of the services provided as opposed to the number of patients served (fee-for-service model)
a. Pay for performance is payment for health care services aligned with quality measures and
performance of the providers, usually through incentives or disincentives.
b. Global or capitation payment with quality benchmarks: A set per-patient fee paid to the provider that
encompasses the total cost of care for patients’ services during a set time interval. May be payment
per patient per month or per year.

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c. Episodes of care or bundled payment: Payment arrangements that include financial and performance
accountability for episodes of care (e.g., a set fee for a hip replacement)
d. Risk sharing
i. Full risk is when the organization and providers are at full financial risk for negative events that
increase costs, such as hospitalizations.
ii. Partial risk or risk sharing is when the organization and the payer share the financial risk for
negative events that increase cost. The shared percentage is usually pre-negotiated.
iii. Prometheus payment is usually a capitated payment model that is continuously restructured
during a set period and is based on how the organization compares with the average quality
measure in its community or region.
2. Health Care Payment Learning & Action Network (HCPLAN). In January 2015, CMS announced plans
for 90% of Medicare payment to be tied to quality or value through alternative payment models by 2018.
This was followed by a similar announcement from the commercial sector. In March of 2016, MACRA
was passed with dramatic changes in payment for strategy discussed under the reimbursement section
later in this chapter. As part of the act, the HCPLAN was established. It is a collaborative network of
public and private stakeholders, including health plans, providers, patients, employers, consumers, states,
and federal agencies within the health care community. These stakeholders will accelerate the adoption
of value-based payment by working together through the Learning & Action Network (LAN) to align
efforts, capture best practices, disseminate information, and apply lessons learned. A Guiding Committee,
multi-stakeholder work groups, and single-sector affinity groups will play critical roles in this work. The
LAN, through its work groups, has produced several guidance documents. In the Alternative Payment
Model Framework white paper, it presents the following payment model framework: (https://hcp-lan.org/
groups/apm-refresh-white-paper/) (See Figure 1).

D. Defining Quality
1. There is no universally accepted definition for what defines health care quality. Differences in perspective can
drive what any one individual or entity may consider as quality, resulting in layers of complexity in attempts
to define the term. The various perspectives may not be well aligned, further contributing to the problem.
a. Patients – May primarily care how they are treated or if they feel better
b. Provider – May care about surrogate measures such as blood pressure or improvement in disease
c. Administrator – May care that services are efficient and not costly to the organization
d. Payer – May care that their hospitalizations are reduced as well as their overall health care costs
2. The IOM defines quality as the degree to which health services for individuals or populations increase the
likelihood of desired health outcomes that are consistent with current professional knowledge (IOM 1990).
Although not considered a universal definition, it encompasses what many would consider as quality.
3. World Health Organization definition of quality
a. Safe: Delivering health care that minimizes risks and harm to service users, including avoiding
preventable injuries and reducing medical errors
b. Effective: Providing services based on scientific knowledge and evidence-based guidelines
c. Timely: Reducing delays in providing and receiving health care
d. Efficient: Delivering health care in a manner that maximizes resource use and avoids waste
e. Equitable: Delivering health care that does not differ in quality on the basis of personal characteristics
(e.g., sex, race, ethnicity, socioeconomic status)
f. People-centered: Providing care that considers the preferences, aspirations, and culture of individuals
and their community

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Alternative Payment Models

THE APM FRAMEWORK
This Framework represents payments from public and private payers to provider organizations (including payments between the
payment and delivery arms of highly integrated health systems). It is designed to accommodate payments in multiple categories
that are made by a single payer, as well as single provider organizations that receive payments in different categories—potentially
from the same payer. Although payments will be classified in discrete categories, the Framework captures a continuum of
clinical and financial risk for provider organizations.

CATEGORY 1 CATEGORY 2 CATEGORY 3 CATEGORY 4

FEE FOR SERVICE – FEE FOR SERVICE – APMS BUILT ON POPULATION –
NO LINK TO LINK TO QUALITY FEE-FOR-SERVICE BASED PAYMENT
QUALITY & VALUE & VALUE ARCHITECTURE

A A A
Foundational Payments APMs with Condition-Specific
for Infrastructure Shared Savings Population-Based
& Operations (e.g., shared savings with Payment
(e.g., care coordination upside risk only) (e.g., per member per month
fees and payments for payments, payments for
HIT investments) B specialty services, such as
oncology or mental health)
APMs with
B Shared Savings
Pay for Reporting and Downside Risk B
(e.g., bonuses for reporting (e.g., episode-based Comprehensive
data or penalties for not payments for procedures Population-Based
reporting data) and comprehensive Payment
payments with upside (e.g., global budgets or
C and downside risk) full/percent of premium
payments)
Pay-for-Performance
(e.g., bonuses for quality C
performance)
Integrated Finance
& Delivery Systems
(e.g., global budgets or
full/percent of premium
payments in integrated
systems)

3N 4N
Risk Based Payments Capitated Payments
NOT Linked to Quality NOT Linked to Quality

hcp-lan.org

Figure 1. Alternative Payment Model Framework.

Reprinted with permission from Health Care Payment Learning & Action Network

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E. Donabedian Domains to Determine and Measure Quality in Health Care. Dr. Avedis Donabedian proposed
these domains for health care quality measurement more than 25 years ago, and they still are the foundation
of quality improvement today.
1. Structure – How resources and systems affect patient care
2. Process – How provider-patient interactions and the care and services provided affect the patient
3. Outcome – What happens to patients: Further categorized by the (ECHO) model
a. Economic outcomes
b. Clinical outcomes
c. Humanistic outcomes

F. Methods Used by Organizations to Evaluate Quality

1. Lean process:
a. Developed within the Japanese auto industry and subsequently popularized by a Massachusetts
Institute of Technology study. Often called the Toyota method
b. Has five key principles
i. Achieving value outcomes with the least amount of work possible
(a) Define value.
(b) Evaluate work flow for inefficiencies.
ii. Eliminate waste or remove any activity that does not add value, such as:
(a) Overproduction or duplication of action
(b) Waiting for information or other needs
(c) Poor material movement or not having items when and where needed
(d) Excessive motion or time wasted in inefficient movement
(e) Inappropriate processing
(f) Inventory or not having the items needed to provide services
(g) Correction or having to fix errors
(h) Underuse or when something should have occurred but did not
iii. Jidoka or ”just in time”
(a) Automatically detect and stop the process when a problem occurs
(b) Identify defects as close to the source of the problem as possible, and halt the process until
fixed
(c) Ability to respond to day-to-day shifts in demand
iv. Identify value streams
(a) Identify the steps most critical and valuable to the service
(b) Understanding the complex adaptive system (many interacting points that vary with
circumstances)
v. The Lean approach or every worker needs to be a problem solver
2. Six Sigma – By focusing on variations in process, error may be reduced.
a. A method focused on reducing variation and defects within processes to consistently create a desired
outcome
b. Six Sigma is a statistical term of measurement that denotes 0.6 deviations from the mean or 3.4
defects per 1 million opportunities. Six Sigma represents an almost error-free process.
c. The steps in the Six Sigma process are as follows:
i. Identify and define what has to be improved.
ii. Measure what is currently occurring by collecting data; analyze the results.
iii. Use creative solutions to improve, and then control, the process with policies, guidelines, and
strategies.

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3. Plan, do, study, act (PDSA) cycle – Quick and manageable process for small groups
a. This method uses three key questions:
i. What are we trying to accomplish?
ii. What change can we make that will result in improvement?
iii. How will we know that a change is an improvement?
b. Planning stage
i. Aims are established according to the outcome desired.
ii. Strategies for change are developed.
iii. Measures are chosen that will determine whether you achieved your aim.
c. Do phase: Implement the change.
d. Study phase: The change is tested using the defined measures.
e. Act phase: Results are used from the study phase to reenter the cycle for further improvement.

G. Creating Your Quality Program. Consider using a business concept called balanced scorecard that states you
should not focus on only one area of your service (e.g., just patient outcomes). Doing so may result in gains
in one area but failures in the other areas; this in turn may sabotage the overall quality of your program. For
example, if you just focus on blood pressure as an outcome but do not make sure that the staff performing
blood pressure measurements are doing so correctly or that blood pressure measurement is easily captured
in your process, you may not achieve the outcome goal you desire. There are four areas you need to measure
to ensure quality.
1. Structure examples include the following:
a. Staff is adequately trained.
b. Communication systems work and are efficient.
c. Workload is manageable.
d. Employee satisfaction and retention
2. Process examples include the following:
a. Error rates
b. Timeliness of services
c. Documentation meeting standards
d. Task performance quality measures
3. Patient outcomes. Examples include the following:
a. Clinical markers
b. Patient satisfaction (as well as other customers)
c. Care experiences
4. Financial outcomes. Examples include the following:
a. Clinic growth and referrals
b. Cost avoidance
c. Reimbursement and revenue capture
d. Cost/value ratio

H. Although in today’s environment quality measures are often dictated by payers, try to influence measure
choices whenever possible by considering the following characteristics:
1. Meaningfulness
a. The measure must be meaningful to you and your patients.
b. Measure an area known to need improvement.
2. Feasibility
a. Can you collect the data needed?
b. How disruptive will collecting data be to your work flow?

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c. Do you have the resources to collect the data?

d. Will the collection and analysis be timely for action?
3. Actionable
a. You must be able to use the results you obtain.
b. Can you make the necessary changes on the basis of results?

I. Sources for Measures. More than 8000 health care quality measures are currently available, and health care
organizations in the business of measure development continue to create more measures to fill gaps where
quality measurement is needed. Many of these measures have been tested and evaluated with some rigor
to ensure a level of validity and quality. Your service may be affected by many of the measures adopted
by payers and accreditation organizations. It is important to understand measure developers, validators,
promoters, and users so that you can understand the measures you and your organization are asked to report
on, or the measures you are able to choose that are most meaningful for your practice and organization. The
following are a list of the main organizations working on the national stage. Additional organizations not
listed may be important to your particular organization, and you may need to be aware of that work in the
private, state, or local level for your community.
1. Government-related organizations
a. AHRQ
i. Sets national strategy for quality improvement in health care. See Table 3 for current national
quality priority measures important for ambulatory care pharmacists.
ii. Developed a collection of evidence reports titled “Closing the Quality Gap Series” available at
www.ahrq.gov/research/findings/evidence-based-reports/er208-series.html
b. National Quality Measures Clearinghouse (NQMC) was a public resource for evidence-based
quality measures housed by AHRQ. As with the National Guideline Clearinghouse, this repository
is no longer being funded by the federal government. To find measures, you will need to go to the
websites of the measure developer or to a payer to view the lists of measures they are using.
c. Centers for Disease Control and Prevention
i. Healthy People 2020
ii. National Health Interview survey
d. Universal Data System (UDS)
i. Established by Health Resources and Services Administration (HRSA) program for Health
Center Program grantees
(a) Federally Qualified Health Centers (FQHCs)
(b) Migrant Health Centers
(c) Health Care for the Homeless
(d) Public Housing Primary Care Program
ii. In order to reduce measurement burden, the quality requirements for these organizations
are updated yearly. You may find the proposed 2019 requirements at: https://bphc.hrsa.gov/
datareporting/pdf/pal_2018-03.pdf.
e. National Academy of Medicine, formerly called the Institute of Medicine (IOM)
i. An independent, nonprofit organization established under the National Academy of Sciences
ii. Role is to work outside government to provide unbiased and authoritative advice to decision-
makers and the public.
iii. Almost 200 reports on health care quality and patient safety are available.
f. Pharmacy Quality Alliance (PQA)
i. Established as public-private partnerships to assist CMS and health care in general in ensuring
the provision of quality services to Medicare beneficiaries and all patients. PQA’s mission is
optimizing health by advancing the quality of medication use.

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ii. Work groups consisting of multidisciplinary representatives from member organizations

develop measure concepts that are then tested, voted on, and moved forward for public use.

Table 3. National Strategy Priority Measures Important to Ambulatory Care Pharmacists

Most Recent Aspirational
Measure Focus Measure Name/Description Baseline Rate
Rate Target
15.6% overall
14.4%, based 11.1% overall
Hospital All-payer 30-day 12.5% Medicare
on 32.9 million 10.4% Medicare
readmissions readmission rate Part C
admissions Part C
2015
People with a usual source of care
75%
Decision-making whose health care providers sometimes 74.6% 79.2%
2015
or never discuss decisions with them
17.5%
Diabetes control Hemoglobin A1c poor control (> 9%) 18.8% 9.3%
2015
Adults with hypertension who have 68.6%
BP control 46% 85.9%
adequately controlled BP 2015
63.3%
Immunizations Influenza immunization 56.3% 87.8%
2015
Smoking Tobacco use: screening and cessation 88.7%
86.6% 99.1%
cessation intervention 2015
Screening for clinical depression and 36.9%
Depression 23% 75%
follow-up plan 2015
63.5%
Obesity BMI screening and follow-up 60.4% 88.1%
2015
BP = blood pressure.
Adapted from: 2018 National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report. Available at www.cms.gov/
Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/2018-Impact-Assessment-Report.pdf. Accessed September 18, 2019.

g. Quality improvement organizations (QIO)

i. Independent organizations contracted with CMS to improve the effectiveness, efficiency,
economy, and quality of services delivered to Medicare beneficiaries
ii. Located in every state
iii. Work to monitor, educate, and assist providers and patients in the delivery and receipt of quality
services
iv. Have scope-of-work contracts with CMS to focus on certain outcomes. Currently planning
for their 12th scope of work contracts. In past work the QIOs have focused on such areas as
immunizations, diabetes care, infection rates, opioids, and adverse drug events.
h. Alliance for Integrated Medication Management Collaborative (AIMM) (formerly Patient Safety
and Clinical Pharmacy Services Collaborative [PSPC])
i. Initiated by the Health Resources and Services Administration (HRSA) in 2007 to address
adverse medication events for uninsured, isolated, or medically vulnerable patients serviced by
“safety net” providers such as FQHCs
ii. Uses the PDSA process to integrate clinical pharmacy services in patient care settings to
improve patient safety and health outcomes
iii. Membership has expanded to include any multidisciplinary, community-based group with
high-risk patients that has integrated or that can integrate clinical pharmacist services.

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iv. In 2014, became an independent nonprofit organization

v. Focus of quality measurement has been on diabetes, hypertension, hyperlipidemia, and adverse
drug events.
i. National Quality Forum (NQF) created in in 1999 by a Presidential Commission to review health
care quality and consumer protection. Measure endorsement is NQF’s primary role. Criteria for
approval are as follows:
i. Be in the public domain.
ii. Be fully tested for reliability and validity.
iii. Have importance, scientific merit, feasibility, and usability compared with competing similar
measures.
2. Accreditation organizations
a. National Committee for Quality Assurance (NCQA)
i. Founded in 1979 by the managed care industry to review preferred provider organization (PPO)
plans and health maintenance organizations (HMOs)
ii. “Reestablished” itself in 1990 as a private, independent, nonprofit health care quality oversight
organization
iii. Developed the Healthcare Effectiveness Data and Information Set (HEDIS) measures for
employers to evaluate the health plans they use for employee benefits
(a) Providers who contract with these health plans are responsible for meeting the applicable
measures.
(b) HEDIS measures are updated yearly. A significant portion of the HEDIS measures revolve
around medication use and the patient care work of pharmacists in the ambulatory care
setting. The 2019 HEDIS measures are available at: www.ncqa.org/hedis/measures/
iv. Provides accreditation, certification, and recognition programs
(a) ACO accreditation
(b) PCMH recognition
(c) Diabetes management recognition program
b. CPPA
i. Established in 2012 through the efforts of the American Pharmacists Association, the National
Association of Boards of Pharmacy, and the American Society of Health-System Pharmacists
ii. Initial accreditation program offered by CPPA is for community pharmacy practice.
iii. Plans to cover the complete ambulatory practice arena
c. Utilization Review Accreditation Commission (URAC)
i. Grew out of the utilization review industry
ii. Provides a wide variety of accreditation programs
(a) ACO accreditation
(b) PCMH achievement
(c) Drug therapy management accreditation
(d) Mail service pharmacy accreditation
(e) Pharmacy benefit management accreditation
(f) Specialty pharmacy accreditation
(g) Community pharmacy accreditation
(h) Telehealth accreditation
d. Joint Commission: Offers accreditation for medical practices and a certification for primary care
medical homes
3. Professional organizations and collaboratives
a. Institute for Healthcare Improvement (IHI)
b. Patient-Centered Primary Care Collaborative (PCPCC)
c. Physician Consortium for Performance Improvement (PCPI)

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4. Payers: Payers currently are the main drivers of determining quality measurement for most organizations.
Payers are either within a government or commercial sector. The commercial sector commonly uses
NCQA HEDIS measures because they directly relate to the payers’ accreditation. They, however, may
also use measures from other sources and select specific set of measures in contractual agreements with
your organization. Government payers may include state, federal, or the health care exchanges. State
provider payment program requirements for quality measures vary for each state, and if you are providing
services to patients insured under state programs you will need to investigate the quality measure within
the particular state insurance programs. CMS quality programs are used by the Medicare system. In
2016, CMS reported on their Quality Strategy, setting goals, objectives, and expected outcomes based
on the national strategy for quality improvement in health care (Table 4). The current CMS quality
programs are listed later in this chapter.

Table 4. CMS Quality Strategy Goals

• Make care safer by reducing harm caused in the delivery of care
• Strengthen person and family engagement as partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment of chronic disease
• Work with communities to promote best practices of healthy living
• Make care affordable
CMS Quality Strategy 2016. Available at www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/cms-quality-
strategy.pdf. Accessed February 18, 2019.

5. Federal government:
a. Physician Quality Reporting System (PQRS) and Meaningful Use measures from the Medicare
system are no longer in use as of 2017. They are still mentioned as the reporting of measures in both
of these programs from 2016 and will influence the Medicare payment rate to providers in 2018.
Both programs were merged into the MACRA Quality Payment Program (QPP).
b. Quality measurement and MACRA. Quality measurement and payment based on reported quality
measures is the cornerstone of the MACRA law and the changes in reimbursement for Medicare
Part B. The law went into effect January 2017. Eligible clinicians or groups have two avenues of
participation: the Advanced Alternative Payment Models (Advanced APMs) and the Merit-Based
Incentive Payment System (MIPS). Medicare Part B providers required to participate since 2017 are
physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered
nurse anesthetists. For 2019, CMS will add the following eligible clinician types: physical therapist,
occupational therapist, clinical social worker, and clinical psychologist. Guidance for the two tracks
included in the program, the MIPS and the Advanced Alternative Payment Models (APMS), may be
found at the QPP website (https://qpp.cms.gov/).
i. QPP goal is to support patients and clinicians in making their own decisions about health
care using data-driven insights, increasingly aligned and meaningful quality measures and
innovative technology. The program emphasizes high-value care and patient outcomes while
minimizing burden on eligible clinicians.
ii. The QPP objectives
(a) Improve beneficiary outcomes and engage patients through patient-centered Advanced
APM and MIPS policies
(b) Enhance clinician experience through flexible and transparent program design and
iterations with easy-to-use tools.
(c) Increase the availability and adoption of robust Advanced APMs.

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(d) Promote program understanding and maximize participation through customized

communication, education, outreach, and support that meet the needs of the diversity of
physician practices and patients, especially the unique needs of small practices.
(e) Improve data and information sharing on program performance to provide accurate, timely,
and actionable feedback to clinicians and other stakeholders.
(f) Deliver IT systems capabilities that meet the needs of users for data submission reporting
and improvement and are seamless, efficient, and valuable on the front and back end.
(g) Ensure operation excellence in program implementation and ongoing development, and
design the program in a manner that allows smaller independent and rural practices to be
successful.
iii. MIPS is a payment adjustment to all Medicare claims based on the performance data and
performance information submitted by eligible providers.
(a) Providers will be evaluated and scored on four measurement categories. Scoring is based
on a 100-point system where 30 points earned is the minimum not to receive a penalty
and a score of 80% in order to receive the maximum payment bonus (7% over baseline
Medicare payments for results of the 2019 year).
(1) Quality comprises 45% of the score.
(2) Improvement activities comprise 15% of the score.
(3) Cost comprises 15% of the score.
(4) Advancing Care Information comprises 25% of the score.
(b) Measurements that eligible providers submit in 2019 will affect the payments they receive
from Medicare in 2021. Providers’ overall Medicare reimbursement will be adjusted on the
basis of what is reported from 2019 within a range of negative 7% to positive 7%.
(c) Payment is based on a CMS calculated score based on points earned in the four categories.
The point system ranges from 1 - 100 points.
(d) Providers may review and select the quality measures that fit their practice. The goal of
QMP is for practices to choose quality measures that are meaningful to them and the
patients they serve.
(1) Participants must submit data for at least 6 measures for the 12-month performance
period.
(2) One of these measures should be an outcome measure; if there is no applicable outcome
measure, a high-priority measure may be submitted instead.
(3) Providers have 275 measures to choose from, which may be found at https://qpp.cms.
gov/mips/explore-measures/quality-measures?py=2018#measures
(4) A review of the measures from 2018 showed pharmacist services may affect 25%–
30% of the measures that are available to providers
(5) An example of how a reported quality measure earns points is shown in Table 5.
(e) To meet the practice improvement measures, there are are more than 100 options.
A number of the options offer opportunities for pharmacists including medication
management by integrating a pharmacist into the practice, coordinated anticoagulation
management, glycemic management services, etc. The 2018 list of activities may be found
on a link at the following CMS website: https://www.cms.gov/Medicare/Quality-Payment-
Program/Resource-Library/2018-Resources.html. For 2019, CMS is proposing six new
practice improvement activities including several around opioid use such as written and
verbal education regarding opiate and benzodiazepine use. Opportunities exist in practice
improvement activities for pharmacist services as well as quality measures.

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(f) To meet cost performance, providers are evaluated on two measures.

(1) Total per capita cost: assesses total Medicare Parts A & B costs for a beneficiary
during the performance period by calculating the risk-adjusted, per capita costs for
beneficiaries attributed to an individual clinician or group of clinicians.
(2) Medicare Spending per Beneficiary: assesses total Medicare Parts A & B costs
incurred by a single beneficiary immediately prior to, during, and 30 days following a
qualifying inpatient hospital stay and compares these observed costs to expected costs.
(g) Providers have two measure set options in reporting on promoting interoperability. The
options categories and measures are as follows:
(1) Promoting interoperability
(A) Security Risk Analysis
(B) e-Prescribing
(C) Provide Patient Access
(D) Send a Summary of Care
(E) Request/Accept Summary of Care
(2) Transition Measures
(A) Security Risk Analysis
(B) e-Prescribing
(C) Provide Patient Access
(D) Health Information Exchange
(h) Certain groups are not subject to MIPS: providers who have < $90,000 in Part B allowed
charges for professional services, provide care to < 200 Medicare beneficiaries, or provide
< 200 covered professional services under the Physician Fee Schedule.

Table 5. MIPS Quality Measure scoring example.

High-Priority
MIPS Benchmark Minimum Maximum
Measure Title measure? Scored?
Measure # Available Points Points
(# bonus points)
Medication
MIPS #46 Reconciliation Yes (1 pt) Yes Yes 3 10
Post Discharge
Minimum points based on data completeness and maximum points based on performance.

iv. APMs are for those eligible clinicians who are currently in an approved CMS APM.
(a) Requirements for consideration as an APM
(1) Require participants to use certified electronic health record technology (CEHRT)
(2) Provide payment for covered professional services based on quality measures
comparable to those used in the quality performance category of the Merit-based
Incentive Payment System (MIPS).
(3) Either: (1) be a Medical Home Model expanded under CMS Innovation Center
authority; or (2) require participating APM Entities to bear more than a nominal
amount of financial risk for monetary losses
(b) For 2019, eligible clinicians for this track must receive 50% of their Medicare Part B
payments through an advanced APM, and 35% of the Medicare patients seen must be part
of an APM.
(c) This group of eligible clinicians will automatically receive a 5% lump sum bonus over
Medicare fee-for-service billing starting in 2019.

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(d) As of 2018 there are 38 approved APMs. The list may be found at: www.cms.gov/Medicare/
Quality-Payment-Program/Resource-Library/Comprehensive-List-of-APMs.pdf
(e) CMS has stated a goal of moving eligible providers over time from MIPS into APMs.
(f) An option for providers starting in 2019 is for the all-payer combination model for
APM eligibility. Providers may submit their payment arrangements for state Medicaid,
Commercial payers in combination with Medicare to see if through the combination of
alternative payment models they meet the criteria.
c. Five-star quality rating programs. The CMS 2019 star measures are available at https://www.cms.
gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf
i. A mandatory program for Medicare Part C and Part D plans
ii. In 2019, there will be 48 measures to evaluate the performance and quality of services of the
participating plans. The purpose of STAR ratings is to assist beneficiaries in choosing the best
plans and to determine payment and participation in Medicare by plans.
iii. Three medication measures developed by PQA on medication adherence continue in 2019 STAR
measures weighted as a 3, or the highest level for scoring. An additional PQA intermediate
outcome measure added in 2019 is statin use in persons with diabetes.
iv. One process measure, Medication Therapy Management Program Completion Rate for
Comprehensive Medication Reviews for Medicare Part D plans, is continued in 2019 with a
weight of 1 (not an elevated weight because it is a process measure, not an outcome measure).
d. CMS Hospital Readmissions Reduction Program: An important hospital-based quality program for
ambulatory pharmacists to be aware of is the Hospital Readmissions Reduction Program, which is
part of the Hospital Value-Based Purchasing Program started in 2012. The Hospital Readmissions
Reduction Program provides an opportunity for ambulatory pharmacists’ patients care services to
help hospitals realize financial gains and avoid the financial penalty.
i. The program provides financial incentives to reduce costly and unnecessary hospital
readmissions.
ii. A hospital readmission is when a patient has an unplanned admission to any hospital within 30
days for the same specified diagnosis.
iii. Hospital payment for the diagnosis-related group is adjusted according to a calculated risk
adjustment excess readmission ratio for each applicable condition.
iv. Current diagnosis-related groups affected by this quality program are:
(a) Acute myocardial infarction
(b) Heart failure
(c) Pneumonia
(d) Hip and knee surgery
(e) Chronic obstructive pulmonary disease
(f) Coronary artery bypass grafting surgery
e. The CMS APMs all use a set of quality measures within their programs. Although these measures
cross over, it is best to review each program-designated set of measures. Following is an example
outline of one of the largest CMS APM programs, the Medicare Shared Savings ACO.
i. Report on 31 performance measures.
(a) Four domains (Table 6)
(b) Ten of the 31 measures may be positively impacted by pharmacists’ patient care services.
ii. Measures may be changed and updated yearly.

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Table 6. Domains for ACO Measures with Measures Pharmacists May Affect
No. of Individual
Domain Measures Pharmacist Patient Care Services May Affect
Measures
Patient/caregiver
8 Health promotion and education
experience
All-cause unplanned admissions for patients with diabetes
All-cause unplanned admissions for patients with heart failure
Care coordination/ All-cause unplanned admissions for patients with several chronic
10
patient safety conditions
Medication reconciliation post-discharge
Falls: Screening for future fall risk
Preventive care and screening: Influenza immunization
Pneumonia vaccination status for older adults
Preventive care and screening: Body mass index screening and
follow-up
Preventive health 8 Preventive care and screening: Tobacco use: screening and cessation
intervention
Preventive care and screening: Screening for clinical depression and
follow-up plan
Statin therapy for preventing and treating cardiovascular disease
Depression remission at 12 months
Diabetes: Hemoglobin A1C poor control
At-risk population 5
Controlling high blood pressure
Ischemic vascular disease: Use of aspirin or another antithrombotic
Total in all domains 31 16 measures
Information from: Centers for Medicare & Medicaid Services (CMS). Medicare Shared Savings Program Quality Measure Benchmarks for the 2018 and 2019 Reporting
Years. Guidance Document February 2019 Version #2 www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-
quality-benchmarks-guidance.pdf. Accessed February 22, 2019.

J. Challenges to Using Quality Measures

1. Attribution. The ability of the quality measure to describe the quality of a particular provider, team,
organization, etc.
2. Statistical accuracy and sampling. Most measures have not gone through the scientific rigors of research-
based evaluations to ensure the results are statistically accurate or what minimal sample is needed for
accuracy.
3. Accounting for exceptions. Because not all patients are alike, there will be situations where the most
appropriate care is contrary to the measure. A determination has to be made of what percentage is
considered an acceptable exception rate and how providers and organizations are protected when they
deviate from a selected measure when it is the correct patient decision.
4. Risk adjustment. It is well known that for certain populations, the goals of any particular measure may
be more difficult to achieve. Many items may be used to determine risk adjustment such as poverty level,
number and type of diagnoses, age, and social-related risks. How is that accounted for in the measures
chosen for your organization? Many measures do not have risk adjustment specifications, creating a
situation where organizations may refuse to accept those patients who may place them at financial risk
5. Appropriate benchmarks. Current measures are often targeted to one topic that may not reflect the health
of the patient. Are we measuring what matters to patients? Is that what we should be measuring?

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6. Potential for gaming. Gaming refers to documentation that an outcome is achieved, but in reality, the
intent of the outcome did not occur at the patient level. This potential should be a consideration when
choosing measures, and it is more problematic with process measures. For example, a check box can
indicate that counseling was provided to exercise 30 minutes 5 days a week and lead to a value-based
payment. If the patient did not or could not act on the counseling, should that provider be rewarded with
payment?
7. Gaps in measures. Despite the many measures in the marketplace, significant gaps remain in needed
measures. Examples of gaps are measures that assess cost, affordability, and patient engagement.
8. Measurement burden. Because the focus of quality has become a priority for many payers and
organizations, providers and organizations alike are feeling the burden of the measurement requirements.
It is not uncommon for organizations or providers to collect data and report on well over 100 measures.
Many times, the measures are overlapping and redundant yet not similar enough to merge, or they are
narrow in focus. This results in both time and financial burdens and potentially little quality improvement.

K. The Call to Measure What Matters to Patients. IOM Vital Signs: Core Metrics for Health and Health Care
Progress (http://iom.nationalacademies.org/Reports/2015/Vital-Signs-Core-Metrics.aspx). The IOM in this
recent report recommends the development of core measures. For health care in the United States to improve,
there has to be a set of measures that the entire enterprise can use, that are meaningful to all patients, and
that can be affected by health care providers. The IOM has challenged each stakeholder in health care, from
the Department of Health and Human Services to each individual practitioner, to determine which of the
following core measures and priorities they can affect. The IOM has also recommended that leaders in health
care adopt these measures.
1. Keys to development of core measures
a. Are your patients getting better?
b. Are your patients’ opinions, concerns, health care desires respected?
c. Are you causing harm to your patients?
d. Do your patients consider the care you provide accessible, available, and affordable?
2. Proposed core measures and priorities. Although the priority measures listed may not be optimal, they
were determined to be the best available at this time.
a. Healthy people
i. Life expectancy
ii. Well-being
iii. Overweight and obesity
iv. Addictive behavior
v. Unintended pregnancy
vi. Healthy communities
b. Care quality
i. Prevention: Immunizations and disease screening
ii. Access to care
iii. Safe care: Includes medication reconciliation
iv. Appropriate treatment: Reduction in chronic disease, improved control of chronic disease, and
preventable hospitalizations
v. Person-centered care
c. Care
i. Affordability
ii. Sustainability
d. Engaged people
i. Individual engagement
ii. Community engagement

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L. CMS Quality Strategy 2016. The CMS quality strategy report released in 2016 guides the quality strategy
that will be used in quality measurement rules and regulations for Medicare benefits. The strategy will be
guided by the following goals and objectives.
1. Make care safer by reducing harm caused in the delivery of care
a. Improve support for a culture of safety
b. Reduce inappropriate and unnecessary care
c. Prevent or minimize harm in all settings (includes medication errors)
2. Strengthen individuals and their families as partners in their care
a. Ensure all care delivery incorporates person and family preferences
b. Improve experience of care for individuals and families
c. Promote self-management
3. Promote effective communication and coordination of care
a. Reduce admissions and readmissions
b. Embed best practices to enable successful transitions between all settings of care
c. Enable effective health care system navigation
4. Promote effective prevention and treatment of chronic disease
a. Increase appropriate use of screening and prevention services
b. Strengthen interventions to prevent heart attacks and strokes
c. Improve quality of care for people with several chronic conditions
d. Improve behavioral health access and quality care
e. Improve perinatal outcomes
5. Work with communities to promote best practices of healthy living
a. Partner with and support federal, state, and local public health improvement efforts
b. Improve access within communities to best practices of healthy living
c. Promote evidence-based community interventions to prevent and treat chronic disease
d. Increase use of home and community-based services
6. Make care affordable
a. Develop and implement payment systems that reward value over volume
b. Use cost-analysis data to inform payment policies

M. Core Measure Set. There has been great interest in developing a core measure set that would transcend all
health care practice sites. This was the initial plan by CMS for MACRA. However, because of feedback
from providers, the MIPS program altered the core measure set plan to allow providers to select quality
measures that best fit their particular practice from the approved measure list. This allows specialties such
ophthalmology or rheumatology to select more appropriate measures for their populations. CMS did identify
169 measures in the QPP that are considered high priority. Included as high priority are measures such as
controlling blood pressure and 15 measures around medication use. However, CMS was required by the
Patient Protection and Affordable Care Act (PPACA or ACA) of 2010, known as Obamacare, to establish a
core measure set for Medicaid. The 2019 set may be found at www.medicaid.gov/medicaid/quality-of-care/
downloads/performance-measurement/2019-adult-core-set.pdf. The Medicaid set has 20 measures out of the
core set that may be affected by ambulatory pharmacist patient care services. How best to use a high priority
or Core Measure Set is to understand how specific measures may be applicable to your particular group
of patients or service may roll up into larger, more global measures. In Figure 2, this has been graphically
depicted by work from the HCPLAN.

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N. Choosing Measures for your practice. Currently, in the majority of ambulatory pharmacist practices, measures
for your organization are primarily predetermined by the payer. It is important for you to understand what
measures your organization are required to report, which of that measure set your service may have a positive
impact on, and subsequent benefit to the organization and your patients. The most appropriate starting points
are HEDIS for your commercial payers and CMS programs for Medicare. That information coupled with
knowledge of your patient population, payer mix, and organizational contracts will help direct you to the
appropriate measures for your service. Looking to the future, CMS rules for MACRA and its implementation
in the next few years will be key in how organizations incorporate quality measurement into their work flow
and payment methods. It is important to account for the direction of Medicare quality measurement and
address how your services fit into the Medicare quality strategy because it will ultimately determine the
sustainability of your services.

MEASURES BY PURPOSE AREA

PBP Models Summary Performance Atomistic Performance
Objectives Measures Measures
BMI Counseling
Life
Expectancy Quality Smoking Cessation
at Birth of Life Counseling
Better Assess Smoking
Health Healthy
Status
Social Health
Circumstances Behaviors

“Big Dots” “Little Dots”

Granularity

Figure 2. Flow of granular measure to core measures.

Reprinted with permission from Health Care Payment Learning & Action Network.
PBP = population based payment

V. ENSURING THE CONTINUED COMPETENCY OF YOUR STAFF

A. Domains of Competency: It is important to ensure that pharmacists in your practice have the knowledge,
skills, attitudes, and behaviors to successfully provide the ambulatory services in your program. Brown and
Ferrill in 2009 introduced a taxonomy of professionalism that outlines domains of competency.
1. Information competency
a. Base knowledge needed for your practice
b. Self-directed learning; ability and drive to keep up with literature and new knowledge
c. Ability to apply your knowledge to patient care
d. Willing to seek out information when it is not known
e. Wisdom in decisions in unclear or challenging situations
2. Communication competency
a. Compassion as a driver of patient care
b. Empathy as a driver in patient care
c. Self-control in challenging situations

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d. Kindness to patients, caregivers, and coworkers

e. Influence on patients, other providers, and coworkers so that patients receive optimal care to produce
optimal outcomes
3. Character competency
a. Honesty and integrity
b. Humility
c. Takes responsibility
d. Motivated to provide best service possible
e. Moral courage to do what is right, even if it is difficult

B. In 2016, ACCP charged the Certification Affairs Committee to update the ACCP Guideline on Clinical
Pharmacist Competencies that was published in May 2017. The competencies mirror and expand those listed
earlier and are summarized in Table 7.

Table 7. ACCP Description of Clinical Pharmacist Competenciesa

Competency
Elements of the Competencyb
Domain
Assess patients, including identifying and prioritizing patient problems and medication-related
needs.
Evaluate drug therapy for appropriateness, effectiveness, safety, adherence, and affordability.
Develop/initiate therapeutic plans and address medication-related problems.
Direct
Follow up on and monitor the outcomes of therapeutic plans.
patient care
Collaborate with other members of the health care team to achieve optimal patient outcomes
across the continuum of care.
Apply knowledge of the roles and responsibilities of other health care team members to patient
care.
Demonstrate and apply in-depth knowledge of pharmacology, pharmacotherapy, pathophysiology,
and the clinical signs, symptoms, and natural history of diseases and/or disorders.
Locate, evaluate, interpret, and assimilate scientific/clinical evidence and other relevant
information from the biomedical, clinical, epidemiological, and social-behavioral literature.
Pharmacotherapy
Use scientific/clinical evidence as the basis for therapeutic decision-making.
knowledge
Possess the knowledge and experience commensurate with certification in one or more BPS
specialties.
Maintain and enhance pharmacotherapy knowledge, including recertification or other
appropriate methods of self-assessment and learning.
Use health care delivery systems and health informatics to optimize the care of individual
patients and patient populations.
Participate in identifying systems-based errors and implementing solutions.
Systems-
Resolve medication-related problems to improve patient/population health and quality metrics.
based care and
Apply knowledge of pharmacoeconomics and risk-benefit analysis to patient-specific and/or
population health
population-based care.
Participate in developing processes to improve transitions of care.
Design quality improvement processes to improve medication use.

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Table 7. ACCP Description of Clinical Pharmacist Competenciesa (continued)

Competency
Elements of the Competencyb
Domain
Communicate effectively with:
Patients, caregivers, families, and laypersons of diverse backgrounds.
Other health professionals and stakeholders.
Communication Provide clear and concise consultations to other health professionals.
Develop professional written communications that are appropriate to the audience.
Use verbal communications tailored to varied clinical and patient-specific environments.
Communicate with appropriate levels of assertiveness, confidence, empathy, and respect.
Uphold the highest standards of integrity and honesty.
Commit to a fiducial relationship with patients, always working in their best interests.
Serve as a credible role model/leader for students, trainees, and colleagues by exhibiting the
Professionalism
values and behaviors of a professional.
Advance clinical pharmacy through professional stewardship, training of future clinical
pharmacists, and active engagement in professional societies.
Commit to excellence and lifelong learning.
Demonstrate skills of self-awareness, self-assessment, and self-development.
Continuing
Identify and implement strategies for personal improvement through continuing professional
professional
development.
development
Provide professional education to students, trainees, or other health professionals.
Maintain BPS certification to ensure that therapeutic knowledge is up-to-date.
These competencies are necessary to provide CMM in team-based, direct patient care environments. Other competencies should be acquired as the clinical pharmacist
a

progresses through his/her career and engages in additional professional activities.

b
These elements of competency help describe each competency but are not intended to be all-inclusive. Other, related elements may apply, depending on the clinical
pharmacist’s practice setting and activities.

C. Processes to Ensure Competency

1. Determine the minimum or desired training needed to perform the job at hand.
a. Level of base degree or licensure
b. Level of postgraduate training, if desired
c. Level of experience that may offset other requirements
d. Certification required or desired – There are many certifications; some have greater recognition than
do others in practice. Listed are the certifications most commonly recognized.
i. Board Certified Pharmacotherapy Specialist (BCPS)
ii. Board Certified Ambulatory Care Pharmacist (BCACP)
iii. Other
(a) Pediatric
(b) Psychiatric
(c) Oncology
(d) Geriatric
(e) Cardiology
(f) Infectious Diseases
iv. Certified Diabetes Educator (CDE)
v. Board Certified Advanced Diabetes Management (BC-ADM)
vi. Immunization certification
vii. Other (i.e., anticoagulation, asthma, pain, smoking cessation). Before deciding to obtain
a particular certification, due diligence in ascertaining the quality and recognition of the
certification should be performed.

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2. State laws or payer stipulations on credentials and training

a. Immunization certification
b. New Mexico – Pharmacist-clinician: Requires that additional physical assessment training and 150
hours/300 patient contact preceptorship be supervised by a physician or other practitioner with
prescriptive authority
c. North Carolina – Clinical pharmacist practitioners: Must complete an application with credentials
and all the physicians’ signatures with whom they will be collaborating. Must be approved by the
Board of Medicine and the Board of Pharmacy.
d. California – Advanced practice pharmacists (APPs): Requires the attainment of certification in a
relevant practice area, a postgraduate residency, and 1 year of service under a collaborative practice
agreement or protocol
e. Iowa, Florida, Minnesota, Montana, and Ohio require completion of training requirements to
participate in state programs for the provision of services.
3. Ensuring maintenance of competency
a. Credentialing is a process to ensure or validate that the pharmacist (or health professional) has the
credentials, experience, or demonstrated ability and the license to be granted practice rights and
responsibilities in an organization.
b. Privileging is the granting of approval to perform a set of services within the providers’ scope of
practice in the organization.
c. May be required by a payer or an organization
d. Methods for credentialing and privileging that may occur at time intervals such as 90 days for newly
credentialed and privileged providers to every 24 months for maintenance of privileges.
i. Required to perform a certain number of services during a certain period for which they are
credentialed and/or privileged in providing
ii. Quality evaluation of the services provided by a provider at some period determined by the
organization.
iii. Peer review of a subset of the services provided at regular intervals
iv. Continued education in areas that are credentialed and privileged during a time interval

Practice Case 3

The practice is beginning to appreciate the skill set and level of services provided by the pharmacy practice
faculty, students, and residents. The medical director approaches you about expanding your services to assist in
improving the performance-related quality measures the practice must report to payers. Because the population of
the practice is primarily fee for service, the practice participates in the MIPS program; it is also seeking NCQA
PCMH status. The director, who noted the student resources at the clinic, would like to explore using students to
help identify patients not meeting the medication-related measure goals and establish standard pharmacy inter-
ventions to improve the measures. You recognize this as a good opportunity for students to learn and participate
in a pharmacist-based role as well as an opportunity for scholarship. You engage one of the tenure-track faculty
members to assist you in developing the project as well as a research protocol to study the outcomes of pharmacy
students and pharmacists assisting in measure and pay-for-performance attainment in a primary care office. Your
college is struggling to identify suitable ambulatory experience sites for students, and this opportunity may enable
you to take an additional student for each rotation.

The training of future pharmacists is important for all practitioners to consider as part of their professional
responsibilities. This case is an example of a win-win situation, where students can learn about ambulatory
practice and also provide needed services to the organization at minimal expense.

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VI. REIMBURSEMENT FOR PHARMACIST SERVICES IN THE AMBULATORY SETTING (Domain 4,

Task 2, items 2, 5, and 7)

A. Potential Revenue Sources for Pharmacist Services. Because pharmacists are not federally recognized
providers (there are exceptions with recent advances at the state level in several states), pharmacist services
cannot be directly billed for most patient care services through federal and most state government entities.
(Exceptions are immunizations, diabetes education, and MTM in Medicare Part D through those Prescription
Drug Plans that have that mechanism.) However, revenue for pharmacist patient care services may be captured
through programs that currently exist at the federal level. This section will review the structure and language
of billing based on CMS, critical to understanding how Medicare works and the rationale for the rules that
are established. The opportunities for current and future opportunities for revenue generation for pharmacist
services will follow.
1. Federal government and Medicare services. Medicare is a federal program that provides health coverage
for people 65 or older or who have a severe disability, no matter the income. Government payers are not
for profit and must focus on management of risk because generally they are supporting high-risk patients.
a. Medicare Part A
i. Administers rules and payment for services from hospitals, health systems, long-term care
facilities, and hospice and home health services
ii. Benefit available for all eligible beneficiaries (must have contributed to social security during
one’s life)
b. Medicare Part B
i. Administers rules and payments for medically necessary outpatient services
ii. Regulated by rules set forth in the Physician Fee Schedule (PFS)
iii. Covers services provided by those with Medicare Part B provider status. Those with
Medicare Part B provider status are physicians and other nonphysician providers. CMS uses
the terminology qualified health-care providers when referring to providers approved under
Medicare Part B that are nonphysicians and groups from the approved list that may be identified
as eligible to participate in the various programs. The complete list can be found at www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/
MedEnroll_PhysOther_FactSheet_ICN903768.pdf.
(a) Anesthesiology assistants and certified registered nurse anesthetists
(b) Audiologists
(c) Certified nurse midwives
(d) Clinical nurse specialists and nurse practitioners
(e) Clinical psychologists
(f) Clinical social workers
(g) Individuals who provide mass immunization
(h) Physical and occupational therapists in private practice
(i) Physician assistants
(j) Registered dietitians or nutrition professionals
(k) Speech-language pathologists
iv. Covers some preventive services (immunizations) and some home care services
v. Not available to those without Social Security benefits
vi. Eligible beneficiaries may opt out of having this benefit; therefore, not every Medicare patient
has this coverage.

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c. Medicare Part C or Medicare Advantage

i. A Medicare health plan offered by a private company that contracts with Medicare to provide
Part A and Part B benefits. Many plans also provide Part D benefits. Medicare pays a fixed
amount for each beneficiary each month to the contracted companies. Part C must provide
benefits that are at least equivalent to those of traditional Part A and Part B; however, more
benefits may be offered as well.
ii. Beneficiary choice of this model may grow with the implementation of the new models of care.
Medicare Part C has almost doubled over the past 10 years and now enrolls 31% of Medicare
beneficiaries.
iii. Beneficiaries opt to join.
d. Medicare Part D – Prescription benefits
i. Administered by commercial payers or prescription drug plans (PDPs)
ii. Houses MTM services
iii. Beneficiaries opt to join.
2. Private organizations. Most of these organizations are for profit and therefore are more focused on
managing costs as they, unlike government entities, do not need to cover the higher-risk patients that the
government payers have as beneficiaries (low income, disability, etc.).
a. Commercial insurers
b. Self-insured employers or employer groups
c. Types of commercial plans
i. Conventional indemnity plan. Allows the participant the choice of any provider without effect
on reimbursement. Reimburse as expenses are incurred.
ii. Preferred provider organization (PPO). Coverage is provided through a network of selected
health care providers. Enrollees may go outside network but incur larger costs.
iii. Exclusive provider organization (EPO). A more restrictive type of preferred provider organization
plan. Employees must use providers from the specified network. There is no coverage for care
received from a non-network provider except in an emergency situation.
iv. Group Model HMO. Contracts with a single multispecialty medical group. The group may only
see HMO patients, or it may also provide services to non-HMO patients.
v. Staff Model HMO. Closed-panel; members receive services only from providers who are HMO
employees.
vi. Network Model HMO. Contracts with many physician groups to provide services to members.
vii. Individual Practice Association (IPA) HMO. A group of independent providers who maintain
their own offices and band together to contract their services.
viii. Point of service (POS). A POS plan is an HMO/PPO hybrid. They resemble HMOs for in-
network services. Outside of the network are reimbursed like an indemnity plan ( reimbursement
based on a fee schedule or usual, customary, and reasonable charges).
ix. Physician-hospital organization (PHO). Alliances between providers and hospitals to help
providers attain market share, improve bargaining power, and reduce administrative costs.
They sell their services to managed care organizations or directly to employers.
x. Medigap Supplemental Plans. Pays the Medicare deductibles, copayments, and other expenses.
3. State-run programs
a. Medicaid is a state and federal program that provides health coverage for very low income. The
federal government pays a specified percentage of their program costs, which averages 57% of costs
per state.
b. Patients who are eligible for both Medicare and Medicaid coverage are termed dual eligible.
c. Insurance exchanges: The ACA established the Health Care Exchange program in each state. The
purpose of the legislation was to address the many individuals in the United States without health

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care insurance. The exchanges provide individuals, families, and small businesses with the means
and option to purchase health care coverage that meets the rules dictated in the act regarding
affordability, benefits, and market standards. Those with low or modest income have the opportunity
to receive premium and cost-sharing subsidies. States may create their own exchanges, collaborate
with other states, or participate in a federal nationwide exchange.
4. Self-pay, although possible, is not common and is difficult to sustain.

B. Generating Revenue for Pharmacist Patient Care Services

1. Understanding reimbursement terminology and language
a. Healthcare Common Procedure Coding System (HCPCS) codes, often called “Hic-Pic” codes,
describe which service, product, or procedure the patient received from the billing heath care
provider. HCPCS has two levels.
i. Level 1 – Current Procedural Terminology (CPT) codes
ii. Level 2 – Codes for product supplies and services not covered under CPT (e.g., ambulance,
durable medical equipment). Codes range from A to V alphanumeric codes. Examples include
G codes, which are classified as temporary procedures and professional services and include
diabetic education codes; and J codes, which are codes for drugs administered other than oral
method and are often used in outpatient infusion clinics.
b. CPT codes or level I HCPC codes
i. Set of medical nomenclature used to report medical procedures and services to public and
private health insurance programs
ii. These codes were developed and are currently maintained and owned by the American Medical
Association (AMA).
iii. There are three categories of codes. For pharmacist services, only the first category E/M codes
and the last category where MTM codes reside are used to describe pharmacist patient care
services. (Table 8)

Table 8. CPT Code Categories

Category 1
Evaluation and management (E/M): 99201–99499
Example 99211 “incident to” code
Anesthesia: 00100–01999; 99100–99150
Surgery: 10000–69990
Radiology: 70000-79999
Pathology and laboratory: 80000–89398
Medicine: 90281–99099; 99151–99199; 99500–99607
Example 99605–99607 medication therapy management services
Category 2
Supplementary tracking codes that can be used for performance measurement
Category 3
Emerging technology codes

c. E/M codes
i. Five-digit CPT codes that start with 99; describe services related to physician visits in the
ambulatory setting
ii. Documentation requirements for these codes are discussed in the Documentation section.
iii. Requires that evaluation and management services are conducted as defined by the E/M
regulations

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d. Resource-based relative value scale (RBRVS)

i. Standardized reimbursement model created as a method of analyzing resources involved in the
provision of health care services or procedures. Allows for discrimination between the varied
work of physicians.
ii. The RBRVS considers the following factors:
(a) Physician work or the complexity and difficulty of the procedure or visit utilizing time,
technical skill, effort expended, judgment, and stress level
(b) Practice expense, such as rent and wages of staff
(c) Professional liability insurance
iii. A relative value unit (RVU) is assigned to each CPT code; this determines the final payment a
provider will receive for that code.
iv. RVUs are determined yearly by an AMA committee
v. RVUs are adjusted according to geographic practice cost indexes (GPCIs), which are then
multiplied by a conversion factor to determine the payment adjustment for the CPT code. The
conversion factor formula is determined by statute and updated annually.
vi. MTM codes do not have RVUs.
e. ICD-codes: Stands for International Statistical Classification of Diseases and Related Health
Problems (i.e., disease and condition codes), which is a medical classification system maintained by
the World Health Organization under the direction and authority of the United Nations.
i. Describes why the service being billed was provided
ii. The next version ICD-11 was released in 2018 and will be presented by the World Health
Organization in May 2019, for implementation January 2022.
iii. ICD-10 code structure
(a) 69,000 code numbers are available in ICD-10.
(b) All codes are alphanumeric; they begin with a letter followed by a number and then a mix
of letters and numbers thereafter.
(c) ICD-10 code lengths vary from four to seven digits.
f. Medicare Administrative Contractors (MACs) – In the past, also called fiscal intermediaries or
Part B carriers. MACs are private companies contracted with Medicare to administer Medicare
funds to providers. Moreover, MACs provide reimbursement services, medical coverage review, and
audits; respond to provider inquiries; educate providers; establish local coverage determinations;
and process claims. Currently, there are 12 Medicare Part A/B MACs and four durable medical
equipment (DME) MACs. Because MACs may add additional interpretation to CMS billing rules, it
is important to regularly review your region’s MAC website for any additional rules and regulations
pertaining to any billing codes that are being used for your service. You may find more information
regarding the role of MACs and determine whom your MAC may be at the following links: https://
www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-
MAC.html www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-
FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/#zpic
g. Health Care Financing Administration 1500 form (HCFA-1500) and the Electronic Format Called
the 837P
i. The official standard form and electronic format used by individual health care providers (e.g.,
physicians, nurse practitioners) when submitting bills or claims for reimbursement to payers
ii. Primarily a federal government form, but used universally
h. The CMS-1450 (previously called UB-04 or UB-92) and its electronic format called the 837I
i. Form or electronic format used by facilities or institutions (e.g., hospitals, long-term care
facilities) when submitting bills
ii. Some private payers may still use UB-04.

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i. National Provider Identifier (NPI) is a 10-digit identification number available for issue to all health
care providers, including pharmacists, and to all health care organizations in the United States. Must
have NPI for electronic billing and for those who use electronic transaction of protected personal
health information
j. Medical necessity. The services you provide must be deemed medically necessary. CMS defines
medically necessary as “services or supplies that are proper and needed for the diagnosis or
treatment of a medical condition and are provided for the diagnosis, direct care, and treatment of the
medical condition, meet the standards of good medical practice in the local area, and are not mainly
for the convenience of the patient or the provider” (www.medicare.gov/glossary/m.html).
2. Rules and regulations are constantly changing with frequent updates. Staying abreast of these changes
are generally the responsibility of the compliance officer and billing and coding personnel. It may be
difficult to try to keep up with them yourself. Instead, develop relationships with those responsible for
billing in the organization so that you stay informed.
a. Medical billing companies or organizations
b. Compliance officer – Person within an organization responsible for ensuring compliance with
payers, regulators, contractors, and accreditors
c. Office manager
d. You can connect with the Medicare Learning Network and sign up for their e-newsletter and other
resources (www.cms.gov/Outreach-and-Education/Outreach-and-Education.html). This is highly
recommended because CMS has made significant effort through this forum to assist providers in
understanding the rules and regulations of their programs.

C. Medicare Rules for Billing – By law, Medicare beneficiaries must be billed usual and customary prices. This
means that a provider cannot discriminate against Medicare patients in billing or give another group of patients
a substantially cheaper rate for the same service. Consequently, most organizations will follow Medicare
rules for all patients (non-Medicare patients) unless there are specific state rules for state-run programs or
unless there is an existing contractual relationship that dictates a different process with commercial payers.

D. Institutional Revenue Generation Options for Pharmacists – Medicare Governed by the Hospital Outpatient
Prospective Payment System (HOPPS or OPPS)
1. “Facility fee” billing
a. Typically used for non–Medicare B-recognized providers who are employed, contracted, or leased
by a hospital or health system
b. Essentially pays the hospital the costs of using the facility to provide services to the beneficiary
c. Use Ambulatory Payment Classification (APC) system codes – a coding system housed under
HCPCS II).
d. APC was established as a method of paying for facility outpatient services; it is analogous to the way
in which inpatient services or diagnosis-related groups are paid.
e. When billing the facility fee as of 2015, APC code 5012 is used together with the HCPCS II G0463
code.
2. Requirements for facility fee billing
a. Medically necessary
b. Sufficiently documented
c. Established patient (seen within the past 3 years)
d. Meet “incident to” rule requirements – See Table 9. Changes in requirements specific for HOPPS are:
i. The supervising provider must be in the building where the “incident to” services are being
performed.
ii. Must have an employee relationship with the hospital as an employee, leased employee, or
independent contractor.

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3. Barriers for facility fee billing

a. Copayment for the patient for Medicare
b. May be lumped into deductibles for commercial payers

E. Clinic or Physician Office Revenue Options for Pharmacists – Medicare

1. “Incident to” billing is an indirect billing mechanism whereby auxiliary personnel under their state
scope of practice may provide patient care services under the direct supervision of a physician or other
approved Medicare Part B provider (physician, physician assistant, nurse practitioner, clinical nurse
specialist, nurse midwife, or clinical psychologist). The service must be a necessary service that is under,
and integral to, the service provided by the approved Medicare Part B provider. Medicare Part B pays
for management for medical conditions or problems; it does not pay for medication management, which
CMS considers a Part D benefit.
2. Requirements for “incident to” billing. Patient must be established with the practice (seen in the practice
within the past 3 years).
a. Must have a face-to-face visit with the physician before the “incident to” visit
b. Service must be medically necessary.
c. Service is an integral, although incidental, part of the physician’s service.
d. Service is commonly provided in the physician’s office.
e. Service is part of the physician’s bill.
f. Must be provided under direct supervision by the physician (physician must be present in the office
space)
g. The physician must be actively involved by continuing to have face-to-face visits and E/M of the
problem associated with the “incident to” billing. There are no hard and fast rules on frequency, but
the industry often suggests the one-in-three rule, or physician sees patient every third visit.
h. The service provided must be within the state scope of practice of the auxiliary personnel.
i. Meet all the requirements listed in Table 9
3. Levels of billing
a. Five levels (Table 10)
b. Specifics of the required elements outlined in Medicare E/M 1995 or 1997 regulations
4. Medicare changes for 2019: To reduce documentation, as part of the Patients Over Paperwork initiative,
CMS made changes in E&M documentation in the 2019 rules. When relevant information is already
contained in the medical record, practitioners may focus their documentation on what has changed
since the last visit, or on pertinent items that have not changed, and need not re-record the defined list
of required elements if there is evidence that the practitioner reviewed the previous information and
updated it as needed. Additionally, practitioners need not re-document the patient’s chief complaint
and history if it has already been appropriately documented by ancillary staff or the beneficiary. The
practitioner, however, must document that the medical record was reviewed and the information verified.

Table 9. Medicare Requirements for Incident-to Services and Billing

Criteria for Billing Incident-to Services
Physician Office Services Hospital Outpatient Services
Service is provided under the direct supervision of an
Service is provided under the direct supervision of an eligible physician or non-physician practitioner. Defined
eligible physician or non-physician practitioner. Defined as present on the same campus where the services
as within the suite or office space where the service is are being furnished or present within the off-campus
performed and immediately available to furnish assistance provider-based department if the setting is off-campus,
and immediately available to furnish assistance

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Table 9. Medicare Requirements for Incident-to Services and Billing (continued)

Criteria for Billing Incident-to Services
Physician Office Services Hospital Outpatient Services
Established patient: Patient must be an established patient
with the eligible provider. Must have an initial face-to-
Same
face visit with the provider where the plan of care is
established
Service is an integral, though incidental part of the
Same
eligible provider’s services
Services are commonly rendered without charge or
Same
included as part of the eligible provider’s bill
Physician Office Services Hospital Outpatient Services
Services are of a type that is commonly furnished and
appropriate to be provided in a physician’s offices or Same
clinic
Service must be medically necessary, authorized
Same
(authorized practitioner’s order), and documented
Authorized provider must provide subsequent services at
a frequency that reflects active participation in treating Same
the patient and plan of care
An employee relationship must exist with the hospital
A financial relationship must exist between the auxiliary
as an employee, leased employee, or independent
personnel and the eligible provider
contractor
Services provided are within the scope of practice for the
Same
auxiliary personnel as dictated by the state practice act

5. “Incident to” billing and pharmacist-specific rules and interpretations

a. Pharmacists are considered auxiliary personnel; therefore, supervising eligible Medicare Part B
providers may bill for pharmacists’ services under incident-to rules.
b. Billing at levels higher than 99211 is determined by state scope of practice. MACs have historically
used their ability to establish local coverage determinations to weigh in on what level pharmacists
can bill. However, the 2016 Physician Fee Services rules from CMS provide clarification in the
background section regarding this issue: “the supervising provider should bill and get paid for
‘incident to’ services provided by auxiliary personnel just as if the supervising provider were
personally providing the service.” This would suggest that as long as “incident to” rules are met and
the service is within the pharmacist’s state scope of practice for pharmacy, pharmacists should be
able to bill the range of “incident to” codes that describe their services and that have documentation
supporting the code chosen to be billed.
c. MTM cannot be billed under “incident to” codes because MTM is a Part D benefit, not a Part B
benefit.

F. Special Billing Situations Available for Pharmacists – Medicare

1. Diabetes Self-Management Training (DSMT) G codes
a. G0108 – Individual visits
b. G0109 – Group visits (two patients or more)
c. Billed and paid in 30-minute increments

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d. Requires a physician order that states the following:

i. Initial and follow-up hours needed (maximum of 10 hours/first year, followed by a maximum
of 2 hours each year thereafter)
ii. Topics to be covered
iii. Whether patient should receive individual or group training
e. To bill Medicare, must be accredited from the American Association of Diabetic Educators,
American Diabetes Association, or Indian Health Service program (other payers may not require
certification)

Table 10. Incident-to E/M Code for Billing According to Levels of Service and Required Supporting Elements
Assessments Problem Expanded
N/A Detailed Comprehensive
of care focused problem focused
Level of
N/A Straightforward Low Moderate High
decision-making
Established
patient E/M 99211 99212 99213 99214 99215
codes
CC N/A Required Required Required Required
Extended Extended
≥ 4 elements(1995) ≥ 4 elements (1995)
Brief or Brief or
HPI elements N/A > 4 elements or > 4 elements or 3 from
1–3 elements 1–3 elements
3 from chronic chronic conditions
conditions (1997) (1997)
Complete
Extended
ROS elements N/A N/A Problem pertinent Minimum of 10
2–9 elements
elements
Pertinent or 1 item Complete
PFSH elements N/A N/A N/A from any of the 1 element from 2 or
areas 3 of the 3 categories
2 elements in
Elements from 8
1–5 elements ≥ 6 elements in at least 6 organ
organs systems (1995)
PE elements N/A in ≥ 1 organ 1 or more organ systems or 12
Two elements from 9
system system elements in ≥ 2
organ systems (1997)
organ systems
Usual length of
5 10 15 25 40
visit (minutes)
CC = chief concern; HPI = history of present illness; PE = physical examination; PFSH = past family and social history; ROS = review of systems.
Information from: Centers for Medicare & Medicaid Services Medicare Learning Network. Evaluation and Management Services. Available at www.cms.gov/Outreach-
and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Accessed November 2, 2016.

2. CMS annual wellness visits (AWVs)

a. HCPC II codes
i. G0402 (initial preventive physical examination)
ii. G0438 (initial AWV, once in lifetime)
iii. G0439 (subsequent visits, AWV)
b. Initial preventive physical examination (welcome to Medicare physical examination) may only be
done by a physician or nonphysician practitioner (not a pharmacist).

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c. This service is only available under Medicare Part B.

d. Will pay either the practitioner or the facility for furnishing the visit
e. Who is eligible to provide AWVs?
i. A physician
ii. Nonphysician practitioners: Physician assistant, nurse practitioner, clinical nurse specialist
iii. Medical professional—defined as a health educator, registered dietitian, nutrition professional,
other licensed practitioner, including pharmacists or a team of such medical professionals—
working under the direct supervision of a physician
f. Initial AWV includes 10 to-dos:
i. Establishment of an individual’s medical/family history
ii. Establishment of a list of current providers and suppliers that are regularly involved in providing
medical care to the individual
iii. Measurement of an individual’s height, weight, body mass index (or waist circumference, if
appropriate), blood pressure, and other routine measurements, as deemed appropriate, based on
the beneficiary’s medical/family history
iv. Detection of any cognitive impairment the individual may have, as defined in this section
v. Review of the individual’s potential (risk factors) for depression, including current or past
experiences with depression or other mood disorders, based on the use of an appropriate
screening instrument for individuals without a current diagnosis of depression, which the health
professional may select from various available standardized screening tests designed for this
purpose and recognized by national medical professional organizations
vi. Review of the individual’s functional ability and level of safety. This may be based on direct
observation, use of appropriate screening questions, or a screening questionnaire selected by the
health professional, who may select from various available screening questions or standardized
questionnaires designed for this purpose and recognized by national professional medical
organizations.
vii. Establishment of a written screening schedule for the individual, such as a checklist for the
next 5–10 years, as appropriate, based on recommendations of the U.S. Preventive Services
Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as
well as the individual’s health status, screening history, and age-appropriate preventive services
covered by Medicare
viii. Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary
interventions are recommended or are under way for the individual, including any mental
health conditions or any such risk factors or conditions that have been identified through an
initial preventive physical examination, and a list of treatment options and their associated risks
and benefits
ix. Furnishing of personalized health advice to the individual and a referral, as appropriate, to
health education or preventive counseling services or programs aimed at reducing identified
risk factors and improving self-management, or community-based lifestyle interventions to
reduce health risks and promote self-management and wellness, including weight loss, physical
activity, smoking cessation, fall prevention, and nutrition
x. Any other element(s) determined appropriate by the Secretary of Health and Human Services
through the National Coverage Determination
g. Subsequent wellness visits: Depression and functional status screening are no longer required for
the visit.
h. As of 2016, CMS will pay a Part B practitioner or a facility for AWV, thus allowing hospitals to
provide this service under HOPPS.

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3. Transitional care management (TCM)

a. CPT E/M codes
i. 99496 (seen within 7 days of discharge) Medical decision-making of high complexity during
the service period
ii. 99495 (seen within 14 days of discharge) Medical decision-making of at least moderate
complexity during the service period
b. May be billed by physicians or qualified nonphysician providers of care management for discharges
from the following:
i. Inpatient hospital setting (including rehabilitation and psychiatric institutions)
ii. Observational setting (less than 48-hour inpatient stay)
iii. Skilled nursing facility
c. Must be discharged to a community setting (home or assisted living)
d. Bundle face-to-face and non–face-to-face coordinated activities into one payment.
e. Face-to-face interview must be done by a Medicare-recognized qualified provider; the non–face-to-
face interview can be done by a provider working within the scope of his or her practice.
f. Pharmacists may do non–face-to-face interviews and coordination of activities and may assist the
physician or other Medicare-recognized provider during the face-to-face visit.
g. Must follow “incident to” rules; however, in 2015, CMS relaxed the rule of direct supervision to
general supervision by the Medicare Part B provider for auxiliary services (includes pharmacists)
for the non–face-to-face coordinated activities with transitions of care. The face-to-face services
remain under direct supervision. General supervision is defined as a direct oversight relationship
between the supervising practitioner and the clinical staff who provide after-hours services.
h. Before 2016, had to bill at 30 days post-discharge, not on date of visit(s). In 2016, able to bill on date
of service. However, if the patient is readmitted within 30 days, and the practice has already billed
TCM for that patient, they cannot bill for TCM when the patient is discharged the second time. If the
patient is readmitted and the practice has not yet billed, they can wait until the patient is discharged
the second time, track the patient for TCM, and bill after the second face-to-face visit.
i. Required components for billing
i. Communication with patient or caregiver within 2 days of discharge
ii. Face-to-face visit within either 7 or 14 days
iii. Required documentation
(a) Complexity of medical decision-making (moderate or high)
(b) Date of discharge
(c) Date of interactive contact with patient or caregiver
(d) Date of face-to-face visit
iv. Only one health care professional may report TCM services.
j. Components of service that may be furnished by physicians or other Medicare-recognized providers
i. Obtaining and reviewing discharge information
ii. Reviewing the need for follow-up on pending diagnostic tests and treatment
iii. Interacting with other health care providers (specialists) who will assume or reassume care of
the beneficiary
iv. Providing education
v. Establishing or reestablishing referrals and arranging needed community resources
vi. Assisting in scheduling any required follow-ups with community providers and services
k. Components of service that may be furnished by non–Medicare-recognized health care providers
i. Communicating with agencies and community services used by the beneficiary
ii. Providing education to support self-management, independent living, and activities of daily living
iii. Assessing and supporting treatment regimen adherence and medication management

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iv. Identifying available community and health resources

v. Assisting the beneficiary and/or family in accessing needed care and services
l. Cannot be billed under Part A
m. Cannot be billed simultaneously with a global period procedure code (see regulations for list of
codes). These include home health care services, care plan oversight, chronic care management
(CCM), and end-stage renal services.
4. “Incident to” visits for CCM – CMS, in efforts to support primary care and recognize CCM as a critical
component of primary care, has created initiatives to improve payment for, and encourage long-term
investment in, CCM. In 2017 CMS added additional codes with increased payment for more complex
patients.
a. Requirements for billing all available CCM codes
i. An initiating visit must be done by a Medicare Part B–eligible provider for any new patient or
patients not seen within 1 year before the provider billing for CCM services.
(a) The eligible provider may use any of the following visit types: an AWV, IPPE, or face-to-
face E/M visit (level 4 or 5 visit not required).
(b) CMS provided an add-on code to the initiating visit, recognizing that establishing the
plan of care may require extensive assessment and care planning beyond the usual effort
described by the separately billable CCM initiating visit. The code is G0506.
ii. Beneficiary or patient requirements
(a) Multiple (two or more) chronic conditions
(b) Chronic conditions expected to last at least 12 months, or until the patient’s death
(c) Chronic conditions place the patient at significant risk of death, acute exacerbation/
decompensation, or functional decline.
iii. A comprehensive care plan is established by the billing-eligible provider and is implemented,
revised, or monitored by the health care team.
iv. As noted with TCM, CMS provides an exception to incident-to rules of general versus direct
supervision and states that the auxiliary personnel need not be a direct employee.
b. Additional rules
i. Copayment from beneficiary required
(a) For dual-eligible patients, state Medicaid is required to pay the copayment.
(b) For patients with private Medicare supplement insurance, the insurance is required to pay
the copayment.
(c) For patients with a secondary to Medicare full health care insurance plan (e.g., employer-
based plan), the insurance is not required to pay the copayment.
ii. Patient consent must be obtained before furnishing or billing for CCM services. This may
be done verbally or it may be written, but it must be documented in the medical record. The
consent should include:
(a) Availability and description of the service and the applicable cost-sharing
(b) The beneficiary of the right to stop the CCM services at any time, effective at the end of a
calendar month
(c) Only one practitioner can furnish and be paid for these services during the calendar month
service period.
c. Required scope-of-service elements
i. The patient must have access to the practice for urgent needs 24 hours a day, 7 days a week for
CCM services. The patient must be provided a means to make timely contact with health care
providers in the practice to address the urgent care needs. The practice should use available
enhanced opportunities for communication such as:
(a) Secure messaging

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(b) Telephone access

(c) Internet
(d) Other asynchronous non–face-to-face consultation methods
ii. Continuity of care with a designated practitioner or member of the care team with whom the
patient can obtain successive routine appointments
iii. Care is comprehensive and includes a systematic assessment of the following:
(a) Patient medical, functional, and psychosocial needs
(b) Timely receipt of all recommended preventive care services
(c) Medication reconciliation with review of adherence and potential interactions
(d) Oversight of patient self-management of medications
iv. An electronic patient-centered comprehensive care plan is created, revised, and/or monitored
and shared electronically or by fax outside the practice, and a copy is given to the patient and/
or caregiver. The care plan should contain the following elements:
(a) Problem list
(b) Expected outcome and prognosis
(c) Measurable treatment goals
(d) Symptom management
(e) Planned interventions and who is responsible for each intervention
(f) Medication management
(g) Community/social services ordered
(h) A description of how services of agencies and specialists outside the practice will be
directed/coordinated
(i) Schedule for periodic review and, when applicable, revision of the care plan
v. Management of all care transitions between and among all health care providers and settings
(e.g., other clinicians, emergency department, or facility discharges). This includes the timely
creation and exchange of continuity of care documents with other practitioners and providers.
vi. Coordination and communication with home and community-clinical service providers, with
note of the patient’s psychosocial needs and functional deficits. This must be documented in
the EHR.
d. EHR requirement
i. Ability to fulfill the scope of service and other elements listed earlier
ii. EHR certified to the edition of certification criteria that is acceptable for the EHR Incentive
Programs as of December 31 of the calendar year before the PFS (PFS payment year)
iii. Meet the final core EHR capabilities (structured recording of demographics, problems,
medications, medication allergies, and creation of a structure clinical summary record)
e. May be billed under HOPPS. Required to inform the patient that hospital personnel are providing
this service
f. Requirements for the specific CCM codes
i. Comprehensive Care Management code 99490
(a) At least 20 minutes of qualified staff time directed by a physician or other qualified health
care provider per calendar month
(b) Only code available to be used by federally qualified health centers and rural health clinics
ii. Complex Comprehensive Care Management codes 99487 and 99489
(a) Evidence of moderate- or high-complexity medical decision-making (as described under
Documentation earlier)
(b) For 60 minutes of clinical staff time directed by a physician or other qualified health care
professional per calendar month, use code 99487.

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(c) For each additional 30 minutes of clinical staff time directed by a physician or other
qualified health care professional per calendar month, use 99489 as an add-on code to
99487 only.
(d) Must meet the time elements to bill each code; cannot use the codes for less time (e.g., 45
minutes instead of 60 minutes) for 99487 or 20 minutes instead of 30 minutes for 99489
iii. May use only CCM or complex CCM code for any given month; may not use both codes in the
same month
g. Telephonic Chronic Care Management - In 2019 CMS is creating three codes for Chronic Care
Remote physiologic monitoring
i. CPT code 990X0 - Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure,
pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.
ii. CPT code 990X1 - Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure,
pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or
programmed alert(s) transmission, each 30 days.
iii. CPT code 994X9 - Remote physiologic monitoring treatment management services, 20 minutes
or more of clinical staff/physician/other qualified health care professional time in a calendar
month requiring interactive communication with the patient/caregiver during the month.

G. Medicare Diabetes Prevention Program (MDPP) - an evidenced-based set of services aimed to help prevent
the onset of type 2 diabetes among Medicare beneficiaries who have prediabetes. MDPP became available to
Medicare beneficiaries as of April 2018.
1. The program
a. Structured sessions with a “coach,” using a CDC approved curriculum to provide training in dietary
change, increased physical activity and weight loss strategies.
b. Twelve months of cores sessions with an additional 12 months of ongoing maintenance sessions for
participants who meet weight loss and attendance goals.
2. MDPP organization requirements - there are a number of requirements for pharmacists and their
organizations to be an approved organization to provide this program. One of the requirements is for
organizations to have full or preliminary CDC Diabetes Prevention Recognition Program (DPRP)
recognition. Further information may be found at: https://innovation.cms.gov/initiatives/medicare-
diabetes-prevention-program/.
3. Coach Eligibility - Likewise there are a number of requirements for Coaches which also may be found
at the above website. In particular coaches must have an NPI number.
4. Documentation - There are a number of documentation requirements also outlined in the above website.
In particular is attendance to sessions and weight loss.
5. Payment - MDPP providers submit claims via usual Medicare Part B processes.
a. Payments are made based on beneficiary attendance and weight loss of 5% from baseline for the first
year and 9% from baseline for the second year.
b. A series of G codes are available for the billing the various steps and outcomes as they occur.
(G9873-G9879, G9880-G9885, G9890, G9891)

H. Community Pharmacy – Part D MTM Services

1. As a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Medicare
contracts with PDPs to provide MTM services.
2. PDPs then contract with pharmacists and/or pharmacies to provide these services or may provide these
services with internal staff.
3. May or may not use MTM codes

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4. Requirements updated yearly in the CMS call letter, usually released in the spring before the year the
regulations are implemented. The following are a summary of the 2019 requirements for Medicare Part
D MTM services:
a. Eligible beneficiaries to have an annual comprehensive medication review (CMR)
i. Interactive person-to-person visit
ii. Telehealth consultation
b. Eligible beneficiaries should have at least quarterly targeted medication reviews (TMRs) with
follow-up interventions when necessary
c. Opt-out only. All eligible beneficiaries are to receive these services unless they decline to participate.
d. May be furnished by a pharmacist or other qualified provider
e. May distinguish between services in ambulatory and institutional settings
f. Must be developed in cooperation with licensed and practicing pharmacists and physicians
g. Measure outcomes of MTM program
i. Examples of drug therapy problem recommendations made as a result of MTM
ii. Examples of drug therapy problem resolutions made as a result of MTM recommendations
h. Interventions for both beneficiaries and prescriber
5. Eligibility for MTM services under Medicare Part D
a. Minimum threshold of two to three chronic health conditions
b. Five of nine core chronic conditions
c. Minimum threshold of two to eight Part D medications
d. Likely to incur Part D drug costs of $4044 or greater

I. MTM CPT Codes

1. 99605: New patient, face-to-face visit: Initial 15 minutes
2. 99606: Established patient, face-to-face visit: Initial 15 minutes
3. 99607: Face-to-face visit
a. For each additional 15 minutes
b. Used only in addition to 99605 or 99606
c. List separately.
4. Summary of current use
a. Lack of universal reimbursement for codes
b. Used in some state Medicaid programs and some prescription drug benefit programs
c. Potential to use in private contract reimbursement

J. Private Payers
1. Contractual relationships in which all aspects of the service are negotiated between the pharmacist and
the payer
2. Can be done with the following:
a. Commercial payers
b. Self-insured employers
c. Health care organizations

K. State-Based Programs that have reimbursement for patient care services under Medicaid. For pharmacists
practicing in these states, the state requirements should be reviewed to determine the reimbursement
opportunities. (Correspondence with Krystalyn Weaver, national Alliance of State Pharmacy Associations
June 2, 2017).
1. California
2. Colorado

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3. Georgia
4. Iowa
5. Kansas
6. Michigan
7. Minnesota
8. Missouri
9. New Mexico
10. North Dakota
11. Ohio
12. Oregon
13. Washington
14. Wisconsin

L. Self-Paying Patients: Depends on the fees established for services and ability to pay by your customers

Practice Case 4

Your site is pleased with the services you are providing. Administration is interested in investigating billing
for your services. You present to administration and the medical staff the options for pharmacist billing in the
physician-based office setting. These include “incident to” physician billing, transition-of-care participation and
billing, chronic care and complex chronic care management billing, and billing pharmacist-conducted follow-up
wellness visits. The compliance officer is not comfortable with the incident to billing of your services because
they are titled MTM, which is not a covered benefit under Part B Medicare. In addition, the reimbursement rate
may not be worth the effort. The office prefers to prepare for MACRA. However, the office is currently strug-
gling with physician schedules for hospital-discharged patients to be seen in the 7-day higher-reimbursed time.
A proposal is developed to use pharmacy services to complete most coordination and transition work within 72
hours post-discharge, either by telephone or within 30 minutes before the physician visit. Reducing time spent by
the physician for discharge visits would create the needed physician visit slots within the 7-day period. Removing
follow-up wellness visits would also create more visit slots in physician schedules. A plan is created to expand
pharmacy services for transition-of-care and wellness visits.

During the past several years, several new opportunities well aligned with pharmacist services have become
available to provide revenue generation to help support pharmacist patient care programs.

VII. SUSTAINING YOUR PRACTICE FOR THE FUTURE

A. Planning for Growth

1. Using structure-related measures (remember the balanced scorecard), monitor the growth of your service
at least quarterly.
a. Number of referrals
b. Number of patients in your clinic
c. Number of visits
d. Complexity of patients
e. Swing patterns of the above measures

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f. Non–patient care workload

i. Quality assurance or pay-for-performance measurement
ii. Research activities
iii. Administrative tasks
(a) Committee work and meetings
(b) Teaching
2. At 90% capacity, have a plan for hiring additional staff.
a. Know the timeline for hiring in your organization.
b. Know the timeline and availability of qualified pharmacists and other staff in your community.
3. Managing growth
a. Short-term solutions
i. Review processes and shift any work that you can to ancillary staff. May be easier to add
ancillary staff, if needed, to your team.
ii. Close your service to new referrals, or refer the patient back to the referring provider for
continued management until you can secure the needed staffing for growth (least desirable).
iii. Redistribute responsibilities in the non–patient care duties for the short term.
b. Long-term solutions
i. Consider cross-training other pharmacists in your organization to assist in coverage during
high-volume periods.
ii. Hire additional practitioners.

B. Strategic Planning. A management activity used to set priorities and direction for your clinic or organization
so that you are adapting constantly to the environment and any changes foreseen
1. Review your current situation and your business plan. Is this the direction you are going? Is it the
direction you want to go? Change what has to be changed.
a. Mission and vision
b. Environmental scan
c. Strengths, weaknesses, opportunities, threats (SWOT) analysis
d. Quality program and balanced scorecard
e. Identify what is needed to achieve excellence in your practice.
f. Reset goals and objectives to achieve the desired level of practice.
2. Setting the time interval. Many strategic plans use a timeline such as 5–10 years. Practice and health
care is a rapidly changing environment, so the strategic planning document may be ongoing and visited
regularly.

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ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS

1. Answer: B are measures for Medicare Part B, which, in 2016-17, is

Previsit planning—including ordering needed tests a fee-for-service model (Answers B and C are incorrect).
before seeing a provider or alerting providers to current HEDIS is a measure set for commercial plans (Answer
issues, new or ongoing—with patients increases effi- A is incorrect).
ciency and work flow in primary care visits (Answer B
is correct). Although it would make sense that technol- 4. Answer: C
ogy and alerts would also improve visits, thus far this Although BCACP status, PGY-2 training and MTM
has not been shown primarily because of inconsistent certification all may be desired credentials, they within
use of technology by providers even when it is available themselves do not guarantee the hire will meet the needs
(Answer C is incorrect). Because patients’ needs and of your organization nor be at the same skill level as
issues are so highly variable, and we know that being you, the organization’s current patient care pharmacist.
patient centered improves care, it is difficult to meet (Answers A, B and D are incorrect). The trust for that
those goals when policies and procedures do not pro- individual will be on his or her performance, thus mak-
vide enough latitude to adjust to individual patient needs ing peer review of services the best option for building
and desires (Answer A is incorrect). The same concern the needed trust and confidence (Answer C is correct).
makes a consistent time frame very difficult to manage if
the goal is to improve patient-specific outcomes (Answer 5. Answer: C
D is incorrect). Under the Hospital Outpatient Prospective Payment
System (HOPPS), all mid-level providers who are
2. Answer: A employees of the hospital and meet “incident to” rules
Making sure the providers are trained in correct blood bill at the same facility fee code. The current revenue
pressure technique is a measure of your clinic struc- for that code is a reasonable reimbursement (Answer C
ture, making sure blood pressure is documented at each is correct). Medication therapy management codes are
visit is a process measure, achieving a blood pressure currently not recognized or payable under Medicare,
goal is an outcome, and knowing how that influences making A an incorrect answer. Answer B is incorrect
the organization’s financial status is an important finan- because “incident to” E/M codes are no longer recog-
cial measure, thus meeting the four key elements of the nized under HOPPS. Although the codes for chronic
balanced scorecard: structure, process, outcomes, and care management in answer D may be used, it is only for
financial measurement (Answer A is correct). Answer those patients who meet the criteria established by CMS.
B is lacking a structure measurement. Usability of the Additionally the reimbursement for CCM codes is cur-
CPOE system would be a structure measure that could rently significantly less than the facility fee.
be used in this case to meet a balanced scorecard with
the other measures listed. Answer C does not have a 6. Answer: B
financial measure component. Answer D does not have Medicare relaxed the “incident to rules” of direct super-
an outcome measure component. vision for aspects of the chronic care management and
transitional care management requirements that may
3. Answer: D be done by auxiliary personnel within their scope of
The Medicare shared savings program was established by practice (includes pharmacists) to bill these particular
CMS under the Affordable Care Act, as a new approach codes. General supervision is felt sufficient because
to health care delivery and to facilitate coordination the Medicare-approved provider in these cases would
and cooperation among providers to improve quality of be setting, sharing, and reviewing the patients’ plans of
care for Medicare beneficiaries and reduce unnecessary care, thus providing general supervision (Answer B is
costs. To participate in the Medicare shared saving pro- correct). Answers C and D are incorrect because they
gram, providers should either be or participating in an require direct supervision; and MTM is not a recognized
accountable care organization (ACO). Participants must billing code under Medicare (Answer A is incorrect).
report on the 33 ACO quality measures established by
CMS (Answer D is correct). PQRS and meaningful use

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 Managing a Clinical Practice

7. Answer: A
Although at this writing we do not know the final ruling,
CMS has stated that the majority of the reimbursement
under MIPS will be for the six measures required for
each provider. Answer C, although true, is not applicable
in this case because PCMH status automatically would
have the provider meet the practice improvement portion
based on the proposed rules. Although patient engage-
ment, Answer B, and improved coordination of care,
Answer D, are important within CMS’s quality improve-
ment plan, at this point it is not clear how those activities
will play into the reimbursement formula. Your best
strategy at this point is to make sure your services con-
tribute to the six core measures that the provider/practice
must choose (Answer A is correct).

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