Innovative Practice Models

Overview
Chronic Care Management (CCM) is defined as non-face-to-face services provided to Medicare patients. Patients are eligible if they have two or more chronic conditions expected to last at least one year or until death. These chronic illnesses pose a significant risk of death, acute exacerbation or decompensation or functional decline. The qualifying list of chronic conditions includes, but is not limited to: Alzheimer’s disease, arthritis, asthma, atrial fibrillation, cancer, chronic obstructive pulmonary disease (COPD), depression, diabetes, heart failure, hypertension, ischemic heart disease or osteoporosis.

Through CCM, pharmacists’ responsibilities are broadened as they play a central role in the multidisciplinary healthcare team. Pharmacists’ impact in improving medication adherence serves as a vital factor of improved patient outcomes. This comes at a pivotal time because as the number of pharmacists continue to increase, the expansion of their contributions are necessary for the pharmacy profession to thrive.

In addition, primary care providers do not have sufficient time to obtain, verify or discuss extensive medication lists with a patient during a routine office visit. Some important advantages of pharmacists in CCM are their accessibility to patients with chronic disease and the ability to help patients manage their complex medication regimens in a timely manner. In the primary care setting, including ACO physician offices, pharmacists have begun to collaborate with physicians on medication optimization, polypharmacy and medication safety. This non-physician healthcare professional also has the ability to assist with preventive interventions (i.e., vaccinations, lipids, osteoporosis).

Pharmacists can play a vital role on the CCM teams by assisting with the care of these patients and working to improve quality benchmark measures. Furthermore, if a physician or another qualified healthcare professional (e.g., pharmacist) spends at least 20 minutes per month during clinical staff time with a CCM eligible patient and establishes, implements, revises or monitors a comprehensive care plan, Medicare will pay for these services under the Medicare Physician Fee Schedule (PFS) using Current Procedural Terminology (CPT) code 99490.

To bill for this fee, it is required to use a certified electronic health record (EHR) for CCM patient encounters and documentation, offer 24/7 access to staff who have EHR access, appoint a practitioner for each patient and coordinate care with proper referral to and from the hospital, specialists or other providers. To maintain CCM services, practices must obtain patients’ consent at least annually.

Billing
Only one practitioner may be paid for CCM services for a given calendar month. This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both). While several eligible provider lists do not mention pharmacists explicitly, CMS stated in 2015 that pharmacists qualify as “clinical staff” and meet the billing requirements for CCM by using “incident to” billing. Therefore, time spent by pharmacists related to CCM of patients in conjunction with physicians, physician assistants and advanced practice registered nurses works to meet the time thresholds specified in the CPT billing criteria listed in the table below. Supervision of pharmacists for the provision of these services does not require the immediate physical presence of the supervising provider.

How to Get Started
CMS requires that the following service components be in place prior to billing for CCM services:

1. Initial visit (in person): This visit can be done through an annual wellness visit or initial preventative physician examination with the patient.
2. Continuous access to care and continuity of care services: The ability to make timely contact with healthcare practitioners in the practice who have access the patient’s medical records 24 hours-a-day, 7 days-a-week.
3. Comprehensive care plan: This care plan must include any electronically captured patient information and must be shared with the patient and/or caregiver.
4. Management of care transitions documentation: Continuity of care documentation must be transmitted electronically to the patient’s other providers by the primary care practice.
5. Home and community-based care coordination: Communication to and from home and community based providers regarding a patient’s needs must be documented in the patient’s medical record.
6. Beneficiary consent: Written consent must be obtained from the beneficiary.

Pharmacists who seek to get involved with CCM services should establish a partnership with a primary care physician and make sure that all of the requirements are in place prior to attempting to bill for CCM.

Overview
On Feb. 24, 2017, the Michigan Department of Health and Human Services (MDHHS) issued Medical Services Administration (MSA) Policy 17-09, pertaining to pharmacy claim reimbursement changes and coverage of pharmacist-provided MTM services. Pursuant to this policy, pharmacists are able to provide MTM services to Michigan Medicaid beneficiaries who are taking at least one medication for a chronic condition (effective April 1, 2017).

Medication Therapy Management (MTM) is, arguably, the cornerstone service of outpatient pharmacy clinical services. Leveraging the unique relationship between patients and their pharmacist, MTM has been shown to improve patient outcomes and reduce overall healthcare costs. While conducting a thorough review of all of a patient’s medications, the pharmacist is positioned to make a positive impact on that patient’s healthcare. Whether the pharmacist is identifying and resolving a drug-related problem, educating a patient about appropriate medication use or recommending a lifestyle change, the pharmacist can improve a patient’s health outcomes through MTM to ensure that long-term health adverse consequences are avoided.

Billing
MSA 17-09 defines MTM services as “face-to-face consultations provided by pharmacists to optimize drug therapy and improve therapeutic outcomes for beneficiaries.”3 Eligible patients enrolled in either fee-for-service (FFS), or any other Medicaid health plan (including managed care programs), are able to receive these services as a “carved-out” benefit reimbursed by Medicaid FFS. Patients who are eligible for MTM services under Medicare Part D are not eligible for MTM services under Michigan Medicaid. Patients who are enrolled in Medicare Part D are not eligible for MTM services under Michigan Medicaid.

Billing for Medicaid MTM services is done utilizing Current Procedural Terminology (CPT) Codes in the CHAMPS platform. It is important to note that processing claims through this system is significantly different from the processing of prescription claims. Pharmacy is unique in that prescription claims processing occurs in real time when prescription claims are submitted to a pharmacy benefit. Medical claims processing operates on a significantly different, and more delayed, timeframe. Note that these CPT codes are submitted by the Pharmacy provider, not the individual pharmacists conducting the intervention. The CPT codes for MTM services provided under this program are shown in the table below.

Patients must be taking at least one medication for a recognized chronic condition to be eligible for these services. The table below identifies the disease states that would render a patient eligible for MTM services. Patient diagnoses should be documented using the ICD-10 format. See the resource compiled by MPA for a full list of eligible ICD-10 diagnosis codes.

Pharmacist Intervention
According to MSA 17-09, MTM services covered under Michigan Medicaid include the following:

• Obtaining necessary assessments of the beneficiary’s health status
• Formulating a medication treatment plan
• Monitoring and evaluating the beneficiary’s response to therapy, including safety and effectiveness
• Performing a comprehensive medication review to identify, resolve and prevent medication-related problems, including adverse drug events
• Documenting the care delivered and communicating essential information to the beneficiary’s other primary care providers
• Referring the beneficiary to his primary care provider or specialist, if necessary
• Providing verbal education and training designed to enhance beneficiary understanding and appropriate use of medications
• Providing information, support services, and resources designed to enhance adherence with the beneficiary’s therapeutic regimens
• Providing an updated personal medication record and medication action plan for the beneficiary
• Coordinating and integrating MTM services within the broader healthcare management services being provided to the beneficiary

How to Get Started
Pharmacists seeking to enroll as MTM service providers for Michigan Medicaid must first obtain a National Provider Identification (NPI) number. NPI numbers can be applied for online through the National Plan Provider Enumeration System here.

Pharmacists will then need to enroll in the CHAMPS platform. The CHAMPS platform can be accessed online through the MILogin platform here.

References & Resources

1. Michigan Department of Health and Human Services. MSA 17-09, Pharmacy Claim Reimbursement Changes and Coverage of Medication Therapy Management Services. Michigan Department of Health and Human Services website. http://www.michigan.gov/documents/
   mdhhs/MSA_17-09_552843_7.pdf.  Accessed on March 2017.
2. Roath E, Malburg D. Delivery of MTM Services for Michigan Medicaid Beneficiaries. Michigan Pharmacists Association website. https://www.michiganpharmacists.org/wp-content/uploads/2022/09/Delivery-of-MTM-Services-for-Michigan-Medicaid-Beneficiaries.pdf.  Published April 2017.

Overview
As of 2014, nine percent of Michigan’s adult population has diabetes with adults aged 65 years and older accounting for 46.9 percent of those people. Only 69.2 percent of adults in Michigan with diabetes participated in a diabetes self-management education program according to 2013 statistics. Additionally, influenza and pneumococcal vaccination rates (58.9 percent and 52.1 percent respectively) in these patients were below ideal levels which presents an add-on opportunity for patient care. This article focuses on the education component as a revenue source in the community pharmacy, but every education encounter provides an additional opportunity for vaccination which also improves the pharmacy’s bottom line.

Billing
Billing for diabetes self-management education (DSME) varies by insurance provider, but many third party payers, including Medicare and Medicaid, offer coverage for DSME for qualified patients participating in accredited programs. As an example, Medicare part B covers an initial 10 hours of training, of which one hour may be done individually.²

Billing is done using CPT codes using the medical billing model.

Additional billing opportunities exist for medical nutrition therapy (MNT) conducted by a licensed or certified registered dietician (RD) or nutrition professional (NP). Three additional hours of initial MNT can be billed but not on the same day as DSME. Partnering with an RD or NP to provide nutrition counseling may benefit the patient and pharmacy. After the initial billing in the first year, each patient is eligible for two additional hours of DSME and two hours of MNT per year.

Pharmacies can always charge patients a cash price and allow them to submit claims to their insurance company for reimbursement. Patients may be willing to pay out-of-pocket for services if they deem them valuable.

Program Accreditation
To be eligible for payment through Medicare Part B, programs must be accredited through either the American Diabetes Association (ADA) or the American Association of Diabetes Educators (AADE). Patients also must have a referral to your program from a physician.2 More information on accreditation can be found at: www.Professional.Diabetes.org/diabetes-education and www.DiabetesEducator.org/practice/diabetes-education-accreditation-program-(deap)/applying-for-accreditation.

Accreditation through the ADA or AADE requires that educational programs adhere to national standards. There are 10 standards:

1. Internal structure
2. External input
3. Access
4. Program coordination
5. Instructional staff
6. Curriculum
7. Individualism
8. Ongoing support
9. Patient progress
10. Quality improvement

AADE offers a useful guide with definitions and requirements for each of the standards that can be found here.

Pharmacist Intervention
Pharmacists provide the educational component of the DSME program which covers a variety of topics including medications, short and long-term complications from diabetes, meal planning, blood glucose monitoring, insulin injection, exercise and much more. The medication component is incredibly important, and one-on-one sessions with patients provide an opportunity to evaluate the appropriateness of the medication regimen. Communication with the patient’s prescriber is important for making alterations in therapy. One approach possibility is working with specific providers who refer patients to the pharmacy’s program and establish a collaborative practice agreement that allows the pharmacist to adjust therapy as needed. Pharmacists who demonstrate positive patient outcomes can utilize that data when discussing their program with physicians.

Practice Examples

• St. Joseph Mercy Oakland offers an accredited DSME program lead by pharmacists and dieticians. Their 10-hour program includes one individual assessment and group education classes along with an individualized meal plan.
• Cub Foods offers a six-month education program, which begins and ends with a personalized health assessment conducted by the pharmacist including an A1c test at each visit to assess progress. Patients have unlimited access to group classes and receive a workbook to help them create and track their own goals.
• Mathes Diabetes Center was created in 2003 and has been accredited since 2009. Located within an independent pharmacy, the center utilizes a pharmacy resident along with staff pharmacists to provide the program. They receive reimbursement through Medicare, Medicaid, some private insurance and cash pay. They offer the program as a four-week course which includes two-hour group classes and individual visits.

Overview
Pharmacists are the medical professionals best equipped to be the experts in pharmacogenomics. What exactly is pharmacogenomics? According to the National Institutes of Health, “Pharmacogenomics is the study of how genes affect a person’s response to drugs. This relatively new field combines pharmacology (the science of drugs) and genomics (the study of genes and their functions) to develop effective, safe medications and doses that will be tailored to a person’s genetic makeup.”

This is an exciting and rapidly expanding a field and presents an incredible opportunity for pharmacists to be the leading experts. We know how drugs work and how the body metabolizes drugs. Most importantly, we understand what the effects can be with altered drug metabolism and can make recommendations for different pharmacotherapies based on those results.

Billing
Direct billing for pharmacogenomic interventions is not widespread yet, even through traditional medical practices, but some insurance companies are beginning to cover the cost of the tests.

Pharmacies currently offering pharmacogenetic testing are primarily using a cash model. Many patients find value in knowing the information and are willing to pay cash up front. They are able to submit information to their insurance companies for reimbursement, but there is no guarantee that the insurance company will pay.

According to an article published in Drug Topics, Rxight^®, a company that conducts pharmacogenetics tests, has developed a business model for community pharmacies where the pharmacogenetics testing is reimbursed by the laboratory and the pharmacist’s time spent on counseling is reimbursed by Rxight^®.

Another billing option is to combine and include pharmacogenetic testing counseling with traditional MTM programs. Depending on the results of the test for a patient, you may be able to bill for additional services such as change in therapy and adherence monitoring through MTM platforms.

Pharmacist Intervention
Pharmacists who wish to provide pharmacogenetics testing in their pharmacies have the opportunity to significantly enhance patient care. Testing companies are continuing to collect data and gathering evidence that by tailoring medication choices to patients based on the results of genetic testing, insurers can save money. Time and money previously wasted on ineffective therapies can be saved. Patients can begin seeing results of their medications more quickly because they will start on a drug with much higher likelihood of success.

One well-established example of a drug-gene interaction is between clopidogrel and liver isoenzyme cytochrome P450 2C19 (CYP2C19). CYP2C19 is responsible for metabolizing clopidogrel into an active metabolite, and patients with genetic variants of CYP2C19 have alterations in how they respond to clopidogrel. Patients with nonfunctional CYP2C19 alleles cannot properly convert clopidogrel into its active form; therefore, they are unable to receive the antiplatelet protection from the drug. Pharmacists, armed with pharmacogenetic information, can intervene with patients and prescribers to recommend alternative treatments that would provide the patients with better antiplatelet protection.

Practice Examples

• In North Carolina, one community pharmacy implemented a program for pharmacogenetic testing of patients taking clopidogrel. They utilized a collaborative practice agreement to facilitate ordering the tests. Prescribers were notified of the results and provided with therapeutic recommendations from the pharmacist. Prescribers were very receptive and accepted the pharmacist’s recommendations.
• Bremo Pharmacy in Richmond, Va., offers pharmacogenetic testing through Rxight. Patients pay a cash price of $399 for the test. They also collaborate with other providers and do need a physician’s order for the test.
• Four community pharmacies developed relationships with physicians for referrals to their pharmacogenetics testing service. Pharmacists collected the sample, interpreted results and made recommendations to prescribers.