Objectives Ambulatory Care Utilizing CDTM Anticoagulation Management Service

Objectives
Ambulatory Care Utilizing CDTM
Anticoagulation Management
Service
• Pharmacy anticoagulation services
• Components to setting up a service
–
–
–
–
–
–
Valery L. Chu, B.S., Pharm.D., CACP
Clinical Pharmacy Specialist – Ambulatory Care
Kingsbrook Jewish Medical Center
Brooklyn, New York
Anticoagulation Management
Services
• > 1000 anticoagulation clinics in US1
• Staffed by physician extenders:
– Clinical pharmacists
– Nurse practitioners
– Physician assistants
• Improve clinical outcomes on anticoagulation therapy
– Reduce anticoagulation adverse events
– For warfarin, increase time in target INR range
Institution support
Reimbursement for services
Lab
Space
Documentation
Support personnel
How to Set Up a Service?
•
•
•
•
•
•
Institution support
Reimbursement for services
Lab
Space
Documentation
Support personnel
• Financial incentives
– Increase institution revenue
– Cost avoidance with lower length of stay
Anticoagulation Forum http://www.acforum.com/locations.html Accessed 3/21/08.
Administration:
Key Players and First Steps
• Identify key departments at institution
–
–
–
–
Pharmacy
Medicine (subspecialties)
Billing/finance
Ambulatory Care
• Prepare proposal
– Outline benefits of service to institution
– Delegate responsibilities
Physicians:
Why Support and What Role?
• Establish value
– Specialized anticoagulation management
– Pharmacist role and expertise
• Identify key physician(s) as service champion
• Partner with physician(s) to practice
• Identify key physicians as initial referrers
• Do not need everyone’s buy-in at start
1
How to Bill for Clinical Services?
“Incident to” Billing
• WHAT?
Service is “... integral, although incidental, part of the
physician’s personal professional services in the course of
diagnosis or treatment of an injury or illness.”
• WHO?
Physician bills for services provided by nonphysicians
Service requires “… direct physician supervision of auxiliary
personnel.”
• WHERE?
Direct supervision requires “… the physician must be present
in the office suite and immediately available to provide
assistance and direction …”
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed March 17, 2008.
Key Billing Terms
Billing
Abbreviation
Term
Description
CPT
Current Procedural
Terminology
Codes to describe health care services
ICD-9-CM
International
Classification of
Diseases, Ninth
Revision, Clinical
Modification
E/M
Evaluation and
Management
- American Medical Association
Codes and classifies morbidity data
- World Health Organization/National Center for
Health Statistics
Subset of CPT codes (99201 – 99499)
that include history, exam, and medical
decision
• “Incident to” billing
• Wording for CPT 99211
– “Office or other outpatient visit for the evaluation
and management of an established patient, that
may not require the presence of a physician.
Usually the presenting problem(s) are minimal.
Typically, 5 minutes are spent performing or
supervising these services.”
• CPT codes for pharmacists to bill not usable
• Partner with billing/finance department to
finalize method
Beebe M, et al. CPT® 2004 Standard Edition American Medical Association; 2004:10
To Describe One Process …
• Patients scheduled under attending physician
clinic
• Pharmacist conducts visit
• Case reviewed with physician if complex
• Pharmacist completes all documentation
• Physician reviews and signs documentation
• Visit billed with:
– CPT 99211
– ICD-9-CM code for diagnosis requiring warfarin
Laboratory Partnership
• Anticoagulation laboratory testing
– Frequent: International normalized ratio (INR)
– Less often: Complete blood count (CBC), basic
metabolic panel (BMP), thyroid panel
• Why work with laboratory?
– Changes in lab workload
• Stat INRs
• Turnaround time for results
– Incorporating INR point-of-care assessment
• Patient sees attending physician periodically
2
Point-of-Care (POC) INR
Point-of-Care INR Devices
• Why POC?
– Rapid results
– Improve workflow
– Enhance provider-patient interaction
• Barriers
– Laboratory buy-in (regulatory concerns)
– Initial acquisition cost
– Maintenance costs (cuvettes, equipment)
Point-of-Care INR Testing:
Which Device to Pick?
• CLIA-waived vs non-waived
(Clinical Laboratory Improvements Amendment)
– CLIA-waived devices Æ low complexity
– Non-CLIA-waived devices Æ moderate-high complexity
• Wishlist
–
–
–
–
–
–
–
Barcode ID scanning
Electronic interface capable
Low sample size
Excellent customer support
Flexible cuvette storage requirements
Easy to use
Low maintenance costs
Point-of-Care INR Testing:
Other Considerations
• Billing for INR lab
– Replaces traditional laboratory
– Determine how test will be billed
• Quality control and correlation studies
– To demonstrate accuracy and precision of results
– To demonstrate reproducibility
– Must be completed prior to patient use
• College of American Pathologists
– Primary group governing laboratory regulations
How to Implement POC Testing
• Partner with Department of Laboratory
– Work with POC coordinator, if present
• Research available devices
• Contact regional institutions for feedback
• Arrange on-site demonstrations
• After device selected:
–
–
–
–
Draft policy and procedure
Delineate responsibilities
Identify individuals to certify
Partner with manufacturer and lab to ensure regulatory
compliance
Space
• Exam room to conduct visits
– Dedicated room
– Assigned room
– Borrowed room
• Close proximity to general clinic area
• Minimum requirements:
– Privacy
– Room for wheelchair + caregiver
– Sink
3
Documentation
Ancillary Support Personnel
Written progress note
• Obtain permission to document
consecutively in progress notes
• Create customized note and have
Medical Records review
Electronic progress note
•
Proprietary software
•
•
•
•
Obtain permission to document in
system
Document level = medical resident
Create customized note template
Software specific to anticoag
documentation and tracking
Interface with existing systems
Summary of Principle
Supporting Depts
• To streamline operation, delegate tasks
• Tasks to assign
–
–
–
–
Triage
INR POC testing
Appointment management
No-show follow-up
• Who?
– Ambulatory care clerical staff
– Nursing
– Pharmacy technicians
Summary of Supporting Depts
LABORATORY
Pharmacy
WHY SUPPORT?
• Advance clinical
services
• Enhance pharmacy
relations with other
depts
ROLE
• Direct admin support
• Liaison for other depts
• Control of personnel
Medicine
WHY SUPPORT?
• Improve patient
outcomes
• Lessen workload
• Access to expertise
ROLE
• Service champion
• Physician
collaborator
• Refer patients
Finance
WHY SUPPORT?
New reimbursable
service
• Clinic impact on lab
workload
• Stat labs and results
turnaround
• Collaboration for POC
• POC testing equipment
budget
• Resource for lab
legislative changes
AMBULATORY
CARE
• Approve appt schedule
• Provide clinic space
• Equipment budget
Supporting
Depts
CLERICAL
ROLE
• Billing method
• Track
reimbursements
• Feedback on billing
method
• Resource for billing
legislative changes
Delegate nonclinical
functions (schedule, make
appt reminders, answer
telephone, etc)
NURSING
• Delegate support tasks
(vital signs, triage, etc)
• Bring patients to exam room
• Identify referrals
INFORMATION
TECHNOLOGY
For electronical medical record,
assist to streamline documenting
4