D.7 - PBM Guidance Pharmacy Clinic Set Up and Stop Code.pdf

PBM Guidance: Pharmacy Clinic Set-up and Stop Code

Pharmacy Benefits Management (PBM) Services Update December 2023, October 2017 - Page 1

Contents December 2023 Update

Background

Oracle Health Background

Discussion

Definitions (VistA/CPRS Facilities)

Definitions (Oracle Health Facilities)

Recommendations (VistA/CPRS Facilities)

In-Person (VistA/CPRS Facilities)

Telephone (Audio Only) (VistA/CPRS Facilities)

Clinical Resource Hubs (VistA/CPRS Facilities)

Connected Care (All Facilities)

Clinical Video Telehealth (CVT) and VA Video Connect (VVC) (Synchronous audio/video) (VistA/CPRS

Facilities)

Remote Patient Monitoring (Formerly Home Telehealth) (VistA/CPRS Facilities)

Secure Messaging (VistA/CPRS Facilities)

E-Consult (VistA/CPRS Facilities)

SCAN-ECHO (VistA/CPRS Facilities)

Chart Consults (VistA/CPRS Facilities)

Inpatient (VistA /CPRS Facilities)

Recommendations (Oracle Health Facilities)

In-Person (Oracle Health Facilities)

Telephone (Audio Only) (Oracle Health Facilities)

VA Video Connect (VVC) (Synchronous audio/video) (Oracle Health Facilities)

Clinical Video Telehealth (CVT) (Synchronous audio/video) (Oracle Health Facilities)

Secure Messaging (Oracle Health Facilities)

Chart Consults (Oracle Health Facilities)

E-Consult/E-Referral (Oracle Health Facilities)

Inpatient (Oracle Health Facilities) http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png

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Remote Patient Monitoring (Formerly Home Telehealth) (Oracle Health Facilities)

Non-Formulary/Prior Authorization (NFPA) Adjudications (Oracle Health Facilities)

Clinical Resource Hubs (Oracle Health Facilities)

Appendix A: Clinical Pharmacy Clinic Set-Up Recommendations (VistA/CPRS)

PACT/Primary Care Clinic Set-up Recommendations

Mental Health Clinic Set-up Recommendations

Pain Clinic Set-up Recommendations

Geriatrics Clinic Set-up Recommendations

Shared Medical Appointments or Groups Clinic Set-up Recommendations

Clinic Set-up Recommendations

Inpatient+ Clinic Set-up Recommendations

Appendix B: Clinical Pharmacy CHAR4 Codes

Appendix C: Clinical Pharmacy E-Consults

Recommendations

Appropriate Use of E-consults

Inappropriate Use of E-consults

Oracle HealthOracle HealthOracle HealthOracle HealthOracle HealthOracle HealthOracle HealthOracle

HealthOracle HealthOracle HealthOracle HealthOracle HealthOracle HealthOracle Health

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November 2023 Update

• Telephone CPT codes have been changed per National Health Information Management

System (HIMS).

o Pharmacists should use the same codes as the face-to-face clinics, with the addition of the -93 modifier to denote the delivery of care was by telephone.

o As of December 2023, the telephone CPT codes of 98966-98968 should no longer be utilized. Per National HIMS, the change allows retaining the description of the original service. Veterans will not be charged a copay for these visits as long as the -93 modifier is appended to the encounter form. The clinic set-up for telephone clinics should remain the same as outlined in this guidance.

• Updated references from Cerner to Oracle Health.

Background Pharmacists within the Veterans Health Administration (VHA) are recognized as leaders in the provision of comprehensive medication management (CMM). It is imperative that VHA pharmacists document the type and volume of patient care encounters not only for VHA workload, documentation, and resource allocation but to advance the recognition of pharmacist advanced practice provider services as described in VHA Handbook 1108.11 Clinical Pharmacy Services. Pharmacy Benefits Management (PBM) has been active since 2007 in establishing national guidance on a consistent process for all facilities related to clinical pharmacy workload documentation and capture, including promoting identification of billing opportunities. In fiscal year 2021, clinical pharmacy encounters reached over 6.2 million.

The American Medical Association (AMA) approved permanent medication management Current Procedural Terminology (CPT) codes in October 2007, which should be used to document pharmacist encounters involving direct interaction with the patient. Approximately one year later, VHA allowed pharmacists to use the 160 (Clinical Pharmacy) stop code in the primary position of the six-digit internal encounter capture system. This change, along with local medical center credentialing and scope of practice advancement, officially recognized the role of pharmacists as advanced practice providers.

This six-digit code combined with a four-digit CHAR4 code has been used to further delineate the pharmacist practice areas and improve granularity of captured workload. It is imperative that pharmacists document patient care encounters appropriately and in compliance with VHA policy and guidance for all inpatient and outpatient patient care that meets the definition of an encounter (e.g., medical history taken, clinical decision making, and documentation).

In 2019, the Managerial Cost Accounting (MCA) Office updated the 160 stop code definition: Records patient visit with a pharmacist for Medication Therapy Management (MTM) - specialized education, instruction, and/or counseling regarding prescribed medications. When the work is completed as a portion of another specialty clinic, use that code in the primary position with Stop Code 160 in the credit position. Use Stop Code 160 as a primary code only when the work is not completed as part of another specialty service. The revised definition, applicable at VISTA/CPRS facilities, continues to support the pharmacist providing care as an advanced practice provider with the clinic set-up of 160 in the primary position, except for noted exceptions in this guidance document.

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=3120

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Oracle Health Background The processes in Oracle Health for workload capture and Stop Code assignment are entirely different from those used in VISTA/CPRS. The complexity of Stop Codes in VISTA/CPRS and the time necessary to monitor and correct issues, or to update in accordance with changing guidance, and reschedule patients as necessary has grown to be excessively burdensome. As evidence, Pharmacists in CPRS had encounters in approximately 76,500 Clinics representing 4,150 unique Primary/Secondary/CHAR4 combinations. Oracle Health has nationally standard data points that can be used to capture much of this data and thus the decision by EHRM was to support only one Stop Code, without Secondary Stop Code or CHAR4. The Oracle Health Appointment Types, the closest approximation to a “CPRS Clinic”, are not used to assign Stop Codes and are only used to ensure patients are scheduled with the correct provider, present at the correct location, and are contacted via the desired modality.

Since Oracle Health captures only one Stop Code per Charge during a Patient Care Encounter, the national decision is to use the Practice Area of the Encounter. This means that usage of Stop Code 160 should be very rare, reserved for instances where there is no other Practice Area being supported by that encounter. Using Stop Code 160 in Oracle Health would only indicate that Clinical Pharmacy work was done by a Pharmacist Provider; this work would not count towards any metrics in the Practice Area(s) they support.

In Oracle Health it was necessary to consolidate existing CPRS Stop Codes due to having only Stop Code per Practice Area. For example: the Home Based Primary Care (HBPC) Stop Codes 156, 157, and 170 through 178 are now represented with a single Stop Code 14A, the Primary Care Stop Codes 323, 338, and 348 are represented with 32A. As of August 2022, 93 CPRS Stop Codes have been consolidated to 34 alphanumeric values.

Another CPRS-to-Oracle Health point to be aware of is that Non-Formulary and Prior Authorization

(NFPA) Adjudications are documented against the submitting provider’s encounter. It is not possible to document the adjudication in another way. There are no CPT codes or Stop Codes associated with NFPA

Adjudications, however, the number of adjudications, and time spent on them, are captured as a discrete data elements and are available in reporting.

There is no build or maintenance for Stop Codes required by managers in Oracle Health. Stop Codes are assigned using a complex process, described later in the document. It is necessary for managers to monitor reports for the Stop Codes being assigned to pharmacists’ encounters to determine whether staff education is needed for the portions they have control over.

Discussion Clinical pharmacy services offered by pharmacists include, but are not limited, to CMM for multiple disease states and conditions, medication therapy management, and medication consultation. These encounters occur in-person and virtually (telephone care, E-consults, telehealth, secure messaging, Pharmacy Benefits Management (PBM) Services Update December 2023, October 2017 - Page 5 electronic medical record (EMR) consults) in both the ambulatory and inpatient setting. These patient care encounters (PCEs) require proper documentation per VHA policy that includes, but is not exclusive to, MCA Office and Health Information Management System (HIMS). The VHA collects workload data to support the continuity of patient care, allocate resources, measure clinical productivity, track performance measures, support quality management, and collect third-party reimbursement. PBM has worked collaboratively with MCA and the HIMS Program Office on the development of standardized processes for clinic set-up and coding for consistent documentation of clinical pharmacy visits throughout VHA. This has also included extensive education to the field.

The pharmacy technician plays an important role, with integrated knowledge of the technical issues and medication use process within VHA. Their role is limited due to the nature and scope of their expertise. Pharmacy technicians may document their work in progress notes, serve to complement the pharmacist’s (or other provider’s) role, and document subjective medication information from the patient. However, pharmacy technicians are not recognized as providers and cannot be listed as providers on an encounter. To capture a PCE, the pharmacist working with the technician would have the responsibility for documenting the required elements of the clinical pharmacy PCE. However, this can only be done if that pharmacist has the documented interaction (e.g., in-person, telephone) with the patient.

Additional information on clinical pharmacy workload capture can be found on the PBM Clinical

Pharmacy SharePoint PBM Clinical Pharmacy Workload Capture.

Definitions (VistA/CPRS Facilities)

• Clinical Pharmacy Patient Care Encounter (PCE). A Clinical Pharmacy PCE includes, but is not limited to, disease management, CMM, medication therapy management, and clinical chart consultation. A PCE can occur in both the outpatient and inpatient setting regardless of practice area or location (e.g., mental health, primary care, acute care, emergency department) and must encompass, at a minimum, three elements: history taking, clinical decision making, and documentation in the medical record (also known as “count workload”). Documentation and generation of PCE can be done by licensed pharmacists, regardless of whether they have an advanced scope of practice. Any clinic used for clinical pharmacy PCE is considered a count clinic, which is a setting that must be designated during clinic set-up in VistA.

• Primary Stop Code. The primary stop code is the first three numbers of a clinic set-up. The primary stop code designates the main clinical group responsible for the care of the patient. Three numbers must always be in the first three characters of an MCA Identifier for it to be valid. Additional Stop Code information can be found at http://vaww.dss.med.va.gov/programdocs/pd_oident.asp.

• Secondary Stop Code. The secondary stop code is the last three numbers of a clinic set-up. It contains the secondary stop code, or credit stop, which serves as a modifier to further define the primary work group or the type of service provided. The secondary stop code is used as a modifier of the work provided in the primary clinical care work unit (identified by the primary stop code).

• Four Character (CHAR4) Code. A CHAR4 code is used by MCA to further define the clinic workload, by program, service, specialty, team, or provider. They are sometimes required for specific National Programs or purposes (e.g., E-Consult) but are otherwise optional. PBM has created a series of http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPO%20Documents/Forms/AllItems.aspx#ServerFilter=FilterField1=Subject%255Fx0020%255For%255Fx0020%255FPractice%255Fx0020%255FArea-FilterValue1=Workload-http://vaww.dss.med.va.gov/programdocs/pd_oident.asp

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CHAR4 codes, which are referred to throughout this guidance and are listed in Appendix B.

Utilization of these codes is strongly encouraged. Previously, CHAR4 Codes were referred to as Alpha Codes or National Codes, but these terms are no longer preferred. Additional information can be found at http://vaww.dss.med.va.gov/programdocs/pd_fourcc.asp.

• Clinical Chart Consultation. A clinical chart consultation, as outlined in VHA Directive 1232, Consult Processes and Procedures, is provided by a pharmacist in response to a formal request seeking opinion, advice, or expertise regarding medication management for a specific patient. It is important to note that any count documentation must meet the definition of a PCE (history, medical decision making, and documentation). The types of chart consultation are:

→ E-Consult: An E-Consult represents provider to provider communication and is used in situations with a single episode of care and to assist providers by addressing a clinical problem or question related to medication management when an in-person visit is not required (e.g., opinion related to a patient specific medication management issue, disease state/therapy specific questions, titration or taper of medications, one-time therapeutic drug monitoring). For additional information on appropriate use of E-Consults and clinic set-up, please refer to Appendix C.

→ Chart Consult: Examples of clinical pharmacy chart consults include prior authorization drug reviews, population management, pharmacokinetic monitoring, and outpatient or inpatient consultations where the patient is not interacted with directly.

→ Automatic Consults: Some facilities utilize automatically triggered consults for pharmacy intervention rather than requiring the provider to enter a consult for each patient. The facility should establish the business rules (or care coordination agreement as appropriate) for these automatic consult triggers to qualify as a PCE, since a consult is not entered by the provider for each patient. The business rule should define how the auto consult is generated (e.g., specific medication, medication classes, specific medication management programs).

Coding for E-Consult, Chart Consult, Automatic Consult: CPT Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management codes 98970-98972 are used to denote services which do not involve direct or virtual patient interaction, rather they are limited to chart review and recommendations for treatment outlined within the documentation in the patient health record via a progress note. For VHA internal use, a patient-initiated request will not be required and may be reported within 7 days of another service for the same problem. Documentation must include clear clinical decision making and communication of detailed treatment plan recommendations for the requesting provider to implement. Time spent must be documented in the progress note for accurate code assignment.

98970 = 5-10 minutes of evaluation and assessment

98971 = 11-20 minutes of evaluation and assessment 98972 = 21 or more minutes of evaluation and assessment http://vaww.dss.med.va.gov/programdocs/pd_fourcc.asp https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230

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NOTE: Per the American Medical Association (AMA) CPT Assistant and CPT Guidelines:

1. Services under 5 minutes cannot be reported. They may be documented in a historical note.

2. The code DOES NOT have a maximum allowable time per the code description “or more”, thus greater than 21 minutes of time is included in the code 98972. No additional codes should be added or quantity greater than 1 reported. Additionally, the service should not be reported as multiple encounters based on time spent.

3. Prolonged services codes cannot be used as “add on” codes with CPT codes from the medicine section 99281 - 99607, which include the codes listed above for capturing additional time. The code description does not indicate a maximum time spent.

Definitions (Oracle Health Facilities)

• Appointment Type: The type of Appointment used for a scheduled visit. The Appointment Type is used to ensure patients are scheduled with the correct Resource, in the correct Location, and the correct Modality; not for workload capture. There is no Stop Code associated with a Oracle

Health Appointment Type.

o Appointment Type Examples: PC Pharm Established Patient, MH Pharm Telephone, Pharm TH Video Home

• Between Visit Encounter (BVE): BVE are encounters that can be created between a patient’s scheduled appointments. They are not used in HBPC, Inpatient, or any Recurring Encounter scenarios. BVEs do not have the necessary requirements to support Charges. Charges should not be submitted on BVEs. However, any actions performed on a BVE are still captured in the way they would be on a scheduled encounter.

• Clinic: The Medical Center or CBOC. There is no direct equivalent of a “CPRS Clinic” in Oracle Health.

• Location: Where a patient checks in for their appointment or, for virtual appointments, where the patient would have checked in if the visit had been in person. The location does not generally affect the assigned Stop Code, with the notable exceptions of Anticoagulation, HBPC, and Emergency/Urgent Care locations.

o Location Examples: 550 Blue PC, 550 MH, 550 Cardiology, 550GA PC, etc.

• FIN: Financial Information Number that identifies the unique patient-encounter combination.

In HBPC, Hospital in Home (HIH), CLC and Inpatient a patient will have one FIN for the duration of their entire enrollment/admission, against which all documentation and workload will be placed.

o The FIN does not have a Stop Code; the Stop Code is assigned to each of the Charges submitted on that FIN. It is possible that multiple Stop Codes are present on the same

FIN.

• Workload: Any action by a user that can be captured electronically; a very all-encompassing term. Examples of Workload: Renewals placed, Consults addressed, IDT time spent, NFPA adjudications

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• Charge: Anything that could be used to bill insurance, whether it has a dollar value or not. This is the equivalent of CPRS Count Workload.

o Charge Examples: CPT Codes, Immunizations Administered, Medications Dispensed, Lab Tests Resulted, Radiology Exam Performed

• Stop Code (aka Company Unit Alias): Stop Codes are in a field called the Company Unit Alias.

The General Ledger Tool (GL Tool) assigns a Stop Code to each Charge approximately 24-48 hours after the visit is completed. There is only one Stop Code per charge; which should be the

Stop Code best aligned with the Practice Area of the Encounter (e.g., 32A for Primary Care).

• Secondary Stop Code: This concept does not exist in Oracle Health. The information traditionally obtained from the VISTA Secondary Stop Code is obtained from other data points in Oracle Health.

• CHAR4: This concept does not exist in Oracle Health. The information traditionally obtained from the VISTA CHAR4 is obtained from other data points in Oracle Health.

• Patient Care Procedure Code (PCPC): A PCPC is a Charge that can be used to codify activities that are outside of the appropriate use of existing CPT, HCPCS, or other Codes. The PCPC is extracted in the same way as a Charge. These are used very sparingly in Oracle Health. Appears in the CDM field.

• General Ledger Tool (GL Tool): A background Oracle Health program that assigns a Stop Code to a charge using an algorithm. The algorithm looks at 11 Qualification Criteria on the Charge and assigns the Stop Code at the first match. The algorithm does not look at all Criteria; it stops evaluating when the first match between the Charge details and the algorithm is made. The algorithm does not consider a combination of Criteria.

o The GL Tool algorithm is VA-custom based on input from VA MCAO and EHRM National

Councils. The GL Tool evaluates Charges submitted the previous day; therefore, the Stop Code is assigned the day after the clinical activity took place.

o Watch 301.3 Workload Credit for Managers - GL Tool Overview.mp4 (sharepoint.com)

• Company Unit Criteria: Categories of Values that can be evaluated by the GL Tool. There is a very loose pattern for the order of Company Unit Values within the GL Tool, which can make understanding Stop Code assignment challenging in some instances. There are additional

Company Unit Criteria but those below are limited to ones that would be applicable to the evaluation of Stop Codes for care provided by Pharmacists.

o Activity Type

▪ A “Folder” which houses the charges that are placed to document care

▪ Pre-determined and not face-up to providers

▪ Example: Charges submitted by a specific PowerForm or group of PowerForms o Charge Description Master (CDM)

▪ Pre-determined label defined by VA that is attached to charges to aid with sorting and providing clinical information

▪ Pre-determined and not visible to providers o Encounter Type

▪ Registration field which indicates the type of encounter such as Inpatient, Outpatient, Between Visit, Telehealth, Telephone, HBPC, Observation https://dvagov.sharepoint.com/sites/VHAClinicalPharmacy/_layouts/15/stream.aspx?id=%2Fsites%2FVHAClinicalPharmacy%2FVideos%2F301%2E3%20Workload%20Credit%20for%20Managers%20%2D%20GL%20Tool%20Overview%2Emp4&referrer=StreamWebApp%2EWeb&referrerScenario=AddressBarCopied%2Eview

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▪ There are additional “Pre” Encounter Types that refer to appointments that are not checked in or planned for the future such as Pre Telehealth, Pre Outpatient, etc.

▪ Face-up to providers o Location

▪ See definition above

▪ Used very sparingly in the GL Tool Algorithm since multiple specialties often share the same Location (e.g., a Check In desk)

▪ Anticoagulation, HBPC, and Emergency Department/Urgent Care locations are the main exceptions where the Location is in the GL Tool

▪ GL Tool cannot use a “wildcard” search o Medical Service Code

▪ Registration field which indicates the medical service being provided, such as

Primary Care, Mental Health, Pain, etc.

▪ Assigned by the MSA during appointment Check In

▪ Generally, very high up in GL Tool; except the Pharmacy Medical Service which is almost the very last item in the GL Tool in an effort to capture any other Stop

Code first

▪ Visible to providers o Provider Specialty

▪ Distinct from the Taxonomy code, distinct from the user’s Role, not visible to users

▪ Pharmacist Providers may have specialties other than Pharmacy assigned

▪ Very low in the GL Tool and would not affect the assigned Stop Code for

Pharmacist Providers as there would be other criteria that would be matched first o Performing Location

▪ A Practice Area manually assigned to a Charge by the provider to aid with Stop Code routing (e.g., VA – Primary Care/Medicine)

▪ Generally, in the middle of the GL Tool algorithm

▪ Required in the Pharmacist Workflow, except for Anticoagulation, Inpatient, HBPC, HIH and other Recurring Outpatient Encounters

▪ Used by Pharmacists to increase the probability that the correct Stop Code is assigned for Between Visit, visits not yet checked in (e.g., Pre Outpatient, Pre Telephone), and those where the MSA assigned the “Pharmacy” medical service

▪ Visible to providers in Charge Viewer

Recommendations (VistA/CPRS Facilities) This guidance provides consistent recommendations for proper pharmacy clinic set-up and workload capture of outpatient and inpatient clinical pharmacy services. This guidance has been created in conjunction with the MCA program office and is consistent with general VA VISTA clinic set-up guidance and VHA Handbook 1108.11. Note: As with all workload documentation, variations in practice may occur at each facility necessitating modifications based on the practice setting of the pharmacist.

http://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=1431

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The PBM Clinical Pharmacy Practice Office (CPPO) recommends that, for facilities on VISTA/CPRS, all clinical pharmacy clinics operating under the oversight of the pharmacy service be given a primary stop code indicative of pharmacy (i.e., 160) since the pharmacist is the main clinical provider responsible for that patient care encounter. There are some exceptions to this, which are described in this guidance.

There are also situations that require specific stop codes in the primary position, such as in the Mental Health (MH), Geriatrics, and Pain Specialty Clinic practice settings (see tables for specific recommendations). If this occurs, it is recommended that the 160 stop code be used in the secondary position when possible (e.g., in order for the contribution of MH Clinical Pharmacist Practitioner (CPP)’s care to be accounted for an individual facility’s access and SAIL metrics it is required for the MH stop code to be in the primary position). Secondary stop codes should be used to further define the primary workgroup or practice setting. In situations where a secondary stop code doesn’t serve this role (e.g., CVT, VVC, telephone), a pharmacy-specific CHAR4 code should be used to define the practice setting

(see Appendix B).

CPPO uses clinic set-up to determine practice area, modality, and primary care status to aggregate and summarize pharmacist encounter data in reports, highlighting the importance of accurate clinic set-

up. To assign a practice area and modality, each clinic location is evaluated from CHAR4 to Secondary Stop Code to Primary Stop Code. The first code to determine a practice area in this order is used. Pharmacy codes (i.e., PHRM and 160) only result in assigning the ‘Pharmacy’ practice area if no other practice area assignment results. The first code to determine a modality in this order is used. If no specific modality is assigned, the assignment is ‘In-Person.’ Primary care status of ‘Yes’ is assigned if the clinic has a stop code or CHAR4 indicating primary care. To see the practice area, modality, and primary care status for each stop code, please refer to PBM CPPO Stop Code and CHAR4 Crosswalk report.

In-Person (VistA/CPRS Facilities)

1. Outpatient or inpatient in-person PCE should be documented in a pharmacy clinic set-up as 160/XXX. The secondary code should be used to identify the pharmacist’s practice area. A

CHAR4 code should be used to further delineate the pharmacist’s practice area, when appropriate.

2. Utilization of 160/000 should be avoided unless a secondary stop code does not exist to define the care being provided by the pharmacist. A CHAR4 code should be used if possible, to define the type of care being provided in this instance.

3. Stop code combinations of 160/160 should be avoided as this does not provide useful information related to clinical pharmacy workload capture.

4. For all PACT clinics, the stop code combination of 160/323 or the appropriate code for specialized PACT clinics should be utilized (see Appendix A).

5. The following geriatric related stop codes are required to be in the primary position. Refer to

Appendix A for specific stop codes.

• 176 (HBPC – Clinical Pharmacist)

• 178 (Telephone HBPC)

• 318 (Geriatric Problem-Focused Consultation Clinic)

• 326 (Telephone Geriatrics) http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png https://vaww.pbi.cdw.va.gov/PBIRS/Pages/ReportViewer.aspx?/GPE/PBM_CPPO/SSRS/PharmacyWorkload/DimStopCodeCHAR4 https://vaww.pbi.cdw.va.gov/PBIRS/Pages/ReportViewer.aspx?/GPE/PBM_CPPO/SSRS/PharmacyWorkload/DimStopCodeCHAR4

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• 350 (GeriPACT)

• 351 (Hospice Care)

• 353 (Palliative Care)

• 354 (Hospital in Home)

6. For all Mental Health (MH) clinics, the applicable MH stop code is to be in the primary position, with 160 as the secondary stop code when possible. Refer to Appendix A for specific stop codes.

7. For all Pain Specialty clinics, the stop code 420 is to be used in the primary position, with 160 as the secondary stop code when possible. Refer to Appendix A for specific stop codes. Note: This is not applicable to Perioperative Pain clinics or pain care being delivered in PACT.

8. The primary stop code in which the CPP provides Complementary and Integrative Health (CIH) treatments, such as Battle Field Acupuncture (BFA), is dependent on whether the clinic is offered within a coordinated stand-alone CIH/well-being clinic (159/160 CHAR4=IACT) or provided within another specialty service (160/159 CHAR4=IACT). Questions related to the CIH Coding Guidance Resources may be sent to the Integrative Health Coordinating Center (IHCC) at vhaopcctintegrativehealth@va.gov.

9. Use the appropriate CPT codes: 99605 for New Patient Initial Encounter for Medication

Management by Clinical Pharmacist; 99606 for Subsequent Established Encounter for Medication Management and 99607 for additional time spent performing Medication

Management with quantity equivalent to each 15 min greater than initial time spent (15 minutes). Time spent performing the service to the patient must be documented in the patient health record to support code assignment. Note: For any single timed CPT code in the same day measured in 15-minute units, providers must provide care greater than or equal to 8 minutes through and including 22 minutes. If the duration of the modality in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be selected.

(Reference: CMS Manual System) For example, if a patient care encounter is 10 minutes, then either 99605 or 99606 is selected. If the care totals 23 minutes or more, then an additional 99607

CPT code may be added.

Telephone (Audio Only) (VistA/CPRS Facilities)

1. Telephone PCE should be documented in a telephone clinic with a primary telephone stop code. Based on the new guidance in August 2022, the secondary stop code for all telephone clinics shall utilize a credit stop code identifying the clinical program/sub-specialty having responsibility for providing care. Please refer to Appendix A for telephone clinic set-up.

2. Telephone clinics should be given a CHAR4 code to further delineate the pharmacist’s practice area.

3. The appropriate CPT code from 99605-99607 with the -93 modifier should be assigned for telephone assessment and management. The total time spent providing the service should be included within documentation in patients’ health record.

Clinical Resource Hubs (VistA/CPRS Facilities)

A Clinical Resource Hub is a centralized VISN or regional service, following a hub and spoke model, that consists of primary care, mental health, and specialty care clinicians who provide care primarily through telehealth modalities to Veterans across various medical centers and CBOCs within their http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png https://dvagov.sharepoint.com/sites/VHAOPCC/shared%20documents/forms/allitems.aspx?viewid=4ba2c7d3%2Dd49a%2D456c%2Da49a%2Db6b2153c997b&id=%2Fsites%2FVHAOPCC%2FShared%20Documents%2FCIH%20Coding%20Guidance%2FAdditional%20Resources%20%28Stop%20Code%2C%20CHAR4%2C%20CPT%2C%20HF%29 https://dvagov.sharepoint.com/sites/VHAOPCC/shared%20documents/forms/allitems.aspx?viewid=4ba2c7d3%2Dd49a%2D456c%2Da49a%2Db6b2153c997b&id=%2Fsites%2FVHAOPCC%2FShared%20Documents%2FCIH%20Coding%20Guidance%2FAdditional%20Resources%20%28Stop%20Code%2C%20CHAR4%2C%20CPT%2C%20HF%29 mailto:vhaopcctintegrativehealth@va.gov https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cms.gov%2FRegulations-and-Guidance%2FGuidance%2FTransmittals%2Fdownloads%2FR2121CP.pdf&data=04%7C01%7C%7Cda4594b5ac954b6d5ce908d9b67b948c%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637741464146135945%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=wxlb1WcIY1dnKXvghoJ14hmYJxA6SRt44r4THcDUV5E%3D&reserved=0

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VISN. The primary mission of VISN CRHs is to support medical centers by improving access to care.

Additional information regarding the CRH is available on the CRH SharePoint. The CRH Clinic Set-Up provides the required clinic set-up for all staff, including the CPS, within the CRHs. Please note, there are both “Hub” and “Spoke” Site clinic set-up worksheets within the CRH Clinic Set-Up workbook.

Connected Care (All Facilities)

Connected Care refers to multiple modalities including Clinical Video Telehealth (CVT), VA Video Connect (VVC), Home Telehealth (HT) (formerly CCHT), Secure Messaging (SM), Specialty Care Access

Network Extension for Community Healthcare Outcomes (SCAN-ECHO), and E-Consults. For guidance on establishing clinical pharmacy services using Connected Care Modalities, please contact your site’s

Telehealth Coordinator and see available resources at:

• VHA Office of Connected Care

• VHA Telehealth Services

Clinical Video Telehealth (CVT) and VA Video Connect (VVC) (Synchronous audio/video)

(VistA/CPRS Facilities)

CVT and VVC PCE should be documented in CVT and VVC clinics with the clinical pharmacy primary stop code of 160 and secondary stop codes specific to CVT and VVC. The appropriate CPT codes for in-person encounters should be utilized with an appended modifier -95 to outline service provided via telehealth modality. There are exceptions to this for Mental Health, Geriatrics, and Pain Specialty clinics which are outlined in Appendix A. Specific to CVT, two clinics and appointments are necessary for each visit: the patient CVT clinic and appointment (at the originating site) and the clinical pharmacist provider clinic and appointment (at the distant site). A CHAR4 code should be used to further delineate the pharmacist’s practice area when an appropriate code is available. See Appendix A for clinic set-up recommendations.

Remote Patient Monitoring (Formerly Home Telehealth) (VistA/CPRS Facilities)

Remote Patient Monitoring Clinical Pharmacy clinic set up will vary according to local practice.

Engagement via remote patient monitoring can be within a unique, standalone program using specific stop codes (Option 1) OR integrated into existing service lines using stop codes specific for the existing service line such as Primary Care (Option 2). It is critical that documentation of workload be done irrespective of the clinic set-up by following the guidance below:

1. Possible documentation options may include:

a. Routine pharmacy clinic set up appropriate to modality used (telephone, in-person, VVC, CVT)

b. Consult service with documentation as chart consult (160/697) for instances when the remote patient monitoring data or results are reviewed and the CPP provides a treatment plan to the remote patient monitoring staff, which is then relayed to the patient.

c. When the pharmacist is assigned to a remote patient monitoring program, remote patient monitoring unique clinical pharmacy service clinics should be set up using http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png https://dvagov.sharepoint.com/sites/VHAOPCCRH https://dvagov.sharepoint.com/sites/VHAOPCCRH/CRHDocuments/Forms/FolderView.aspx?id=%2Fsites%2FVHAOPCCRH%2FCRHDocuments%2FBusiness%20Operational%20Documents%2FCoverage%20Documents%2FClinic%20Setup%2FClinic%20Builds&viewid=dfad017c%2D39d5%2D4e56%2D803c%2Dd46366d2e907 https://dvagov.sharepoint.com/sites/VHAOPCCRH/CRHDocuments/Forms/FolderView.aspx?id=%2Fsites%2FVHAOPCCRH%2FCRHDocuments%2FBusiness%20Operational%20Documents%2FCoverage%20Documents%2FClinic%20Setup%2FClinic%20Builds&viewid=dfad017c%2D39d5%2D4e56%2D803c%2Dd46366d2e907 http://vaww.connectedcare.va.gov/ http://vaww.telehealth.va.gov/ http://vaww.telehealth.va.gov/pgm/ht/index.asp

Pharmacy Benefits Management (PBM) Services Update December 2023, October 2017 - Page 13

160 and remote patient monitoring codes in appropriate positions in consultation with the remote patient monitoring service line. Remote patient monitoring clinics should include the proper CHAR4 to describe the services provided.

Clinic Type Description Primary Stop

Code Secondary Stop

Code

CHAR4

CPP encounter in PACT service line clinics

Remote Patient

Monitoring Option 2 Pharmacy clinic set up appropriate to modality used (telephone, in-person, VVC, CVT) as indicated in Appendix A

DEPC (in-person, telephone, VVC, CVT, secure message)

Consult Service Remote Patient Monitoring results or patients evaluated by CPS;

Remote Patient

Monitoring staff relays treatment plan to patient

160 697 Use appropriate

CHAR4 code (Chart consult or e-Consult

Remote Patient Monitoring

Service Line clinic

Remote Patient

Monitoring Option 1

(separate HT Service)

Remote Patient

Monitoring (See Remote Patient

Monitoring Clinic Set-up)

Use appropriate

CHAR4 code

Please refer to your local Remote Patient Monitoring Coordinator or latest guidance on the National

Home Telehealth Master Document Site for current guidance regarding these options if dedicated Remote Patient Monitoring Service Line (Option 1) exists at your facility.

Secure Messaging (VistA/CPRS Facilities)

National educational presentation (2015) on SM workload credit

1. For the limited number of messages that meet the criteria for a patient care encounter evaluation, the author may utilize the copy and paste functionality to copy a secure message (SM), in its entirety, from the SM application to create a note that is associated with a count, non-billable clinic specifically set up to capture secure messages. The appropriate CPT codes 98970-98972 should be used to report these services which do not involve interaction with the patient. Copy and paste must be monitored to ensure that use is very limited and only utilized when an SM meets the criteria for an online evaluation.

2. The clinic must utilize the secondary stop code 719 to ensure all first and third party billing is suppressed and to allow for accurate capture of information. Secure messaging clinics should always include the appropriate CHAR4 to describe the services provided.

http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png file:///C:/Users/VHAECHMooreT/AppData/Local/Microsoft/Windows/INetCache/Content.MSO/B5F382.xlsx%23RANGE!PCEcc1 file:///C:/Users/VHAECHMooreT/AppData/Local/Microsoft/Windows/INetCache/Content.MSO/B5F382.xlsx%23RANGE!PCEcc1 https://dvagov.sharepoint.com/:w:/r/sites/VHA-Telehealth/_layouts/15/doc2.aspx?sourcedoc=%7B97B8426A-FD5D-427A-BA26-E8DA9DC91AF5%7D&file=ht-coding.doc&action=default&mobileredirect=true&cid=36557218-10d8-4d71-9dd3-b4d2ebbee1fb https://dvagov.sharepoint.com/:w:/r/sites/VHA-Telehealth/_layouts/15/doc2.aspx?sourcedoc=%7B97B8426A-FD5D-427A-BA26-E8DA9DC91AF5%7D&file=ht-coding.doc&action=default&mobileredirect=true&cid=36557218-10d8-4d71-9dd3-b4d2ebbee1fb https://dvagov.sharepoint.com/:w:/r/sites/VHA-Telehealth/_layouts/15/doc2.aspx?sourcedoc=%7B97B8426A-FD5D-427A-BA26-E8DA9DC91AF5%7D&file=ht-coding.doc&action=default&mobileredirect=true&cid=36557218-10d8-4d71-9dd3-b4d2ebbee1fb https://dvagov.sharepoint.com/:w:/r/sites/VHA-Telehealth/_layouts/15/doc2.aspx?sourcedoc=%7B97B8426A-FD5D-427A-BA26-E8DA9DC91AF5%7D&file=ht-coding.doc&action=default&mobileredirect=true&cid=36557218-10d8-4d71-9dd3-b4d2ebbee1fb https://vaww.infoshare.va.gov/sites/telehealth/docs/Forms/ht.aspx https://vaww.infoshare.va.gov/sites/telehealth/docs/Forms/ht.aspx https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/PBMDSS%20Guidance%20Documents/Specialty%20Guidance/Secure%20Messaging%20National%20Ed%20Sessions%202015.pptx

Pharmacy Benefits Management (PBM) Services Update December 2023, October 2017 - Page 14

3. All notes that are copied and pasted from the SM application are mapped to the standard note title “My HealtheVet (MHV) Dialog Note.” There are 3 nationally recognized progress note titles for pharmacy SM: E & M of Anticoagulation Secure Messaging, Pharmacy Secure Messaging, and

Pharmacy Medication Management Secure Messaging. A fact sheet on secure messaging is available on the CPPO SharePoint at the following link: PBM Clinical Pharmacy Workload Capture

FAQs .

E-Consult (VistA/CPRS Facilities)

For information on appropriate use of E-Consults and clinic set-up, see Appendix C. The appropriate

CPT codes 98970-98972 are used to denote services. See definition above for more details regarding coding.

SCAN-ECHO (VistA/CPRS Facilities)

For information on SCAN ECHO clinic set-up, please see the following SharePoint sites.

(Specialty Care Access Network-Extension for Community Healthcare Outcomes) SCAN-ECHO SharePoint

SCAN-ECHO SharePoint Documents VA SCAN-ECHO Clinic Setup document

Chart Consults (VistA/CPRS Facilities)

1. If appropriate criteria are met for a chart consult clinic, outpatient or inpatient PCE can be documented in a pharmacy clinic set up as 160/697 and should be given a CHAR4 code.

2. To meet the criteria for a chart consult clinic, a consult must be received or a business rule (e.g., local medical center policy, committee decision, Care Coordination Agreement) must exist to warrant an “automatic consult” to pharmacy.

3. If the chart consult is generated from an HBPC program area, 176/697 should be utilized.

4. Population health management provides increased access to care for Veterans by providing proactive referral for care through identification of Veterans who may benefit from CPP services. Chart consult utilization for population management documentation must meet the criteria for PCE. Population management can also result in a telephone call clinic encounter with the Veteran for the initial patient contact and intervention. See PBM CPPO Pharmacy Workload Capture FAQs document for additional details.

5. The appropriate CPT codes 98970-98972 are used to denote services. See definition above for more details regarding coding.

Inpatient (VistA /CPRS Facilities)

1. Facilities should accurately capture workload in the inpatient setting for activities performed by clinical pharmacists and CPP. When developing clinics for inpatient PCE, the facility should http://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPOSharepointLogos/CPPO%20Logo%20Wide.png https://dvagov.sharepoint.com/sites/VHAClinicalPharmacy/CPPO%20Documents/PBM%20CPPO%20Pharmacy%20Workload%20Capture%20FAQs.pdf http://vaww.infoshare.va.gov/sites/specialtycare/SCSTransformation/SCANECHO/default.aspx http://vaww.infoshare.va.gov/sites/specialtycare/SCSTransformation/SCANECHO/Information%20from%20Office%20of%20Specialty%20Care%20Transfor/Forms/AllItems.aspx http://vaww.infoshare.va.gov/sites/specialtycare/SCSTransformation/SCANECHO/Information%20from%20Office%20of%20Specialty%20Care%20Transfor/VA%20SCAN-ECHO%20Clinic%20Setup%20(CBO-DSS-HIMS%20approved).doc https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPO%20Documents/PBM%20CPPO%20Pharmacy%20Workload%20Capture%20FAQs.pdf https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/CPPO%20Documents/PBM%20CPPO%20Pharmacy%20Workload%20Capture%20FAQs.pdf

Pharmacy Benefits Management (PBM) Services Update December 2023, October 2017 - Page 15 identify the typical types and frequency of encounters routinely documented. The clinic stop codes used should provide the “best” description of the care provided for the patient population. It is not necessary to develop clinics for each type of activity or area where the clinical pharmacist/CPP functions. Clinic set-up should be structured in a way that helps clinical pharmacy leadership describe the services provided. There may also be a desire to capture workload for CPP differently than other inpatient clinical pharmacists, which should be determined in advance when developing inpatient clinics. There are two tables below that describe ways for clinic set-up by location (practice area) or by activity (service provided). There is no right or wrong way to capture workload in the inpatient setting as long as pharmacists have a means to document their activities in accordance with corresponding clinics.

a. For example, if the pharmacists provide a variety of medication management services across all medical teams, it may be beneficial for the facility to set up a clinic to capture the workload based on general CMM services using pharmacy and medicine specialty codes. However, if the pharmacist provides specific medication management services (pharmacokinetics or anticoagulation management) across all inpatients, it may be more useful to have clinic set-up reflect the activity provided using pharmacy and the activity-specific workload code.

2. Inpatient Clinical Pharmacy PCE will generally fall into one of two categories: in-person or chart consult. This categorization is based on clinical pharmacy practices and activities at individual facilities.

a. An in-person inpatient PCE includes a component of direct patient contact at the bedside. In-person encounters may include discharge counseling and care coordination, medication history taking and reconciliation, or when the clinical pharmacist/CPP performs components of medication management at the bedside

(may be in combination with the medical team) and provides direct communication with the patient (e.g., discusses treatment plan and performs counseling as applicable).

b. If the pharmacist is documenting a PCE in which the patient assessment is made primarily through chart review, then this is considered a chart consult.

It is important that pharmacists have a way to document both types of encounters (in-person or chart consult) in the inpatient setting and choose the clinic based on what applies to the activity, specific patient case, or function. The appropriate CPT code(s) should be utilized within PCE based on the modality and service performed, e.g., face to face, consult.

3. Interventions made by the pharmacist that meets the definition of a PCE is known as “count” workload. There are generally two ways to document clinical pharmacy services in the inpatient setting when not all interventions are considered “count”:

a. Have two separate clinics: one count and one non-count. Complete the PCE for the patients that meet the definition of “count” in the count clinic. For the non-count review, complete the note tied to the non-count clinic. Non-count clinic data does not transmit to most national encounter databases/datasets but can be pulled over as workload credit by MCA within their reports, if you request MCA to do so.

b. Have one count clinic and check the historical box for patients who do not meet the count definition. Checking the historical box means that the visit will not transmit to

Pharmacy Benefits Management (PBM) Services Update December 2023, October 2017 - Page 16 national encounter databases/datasets and will not transmit to MCA for workload credit.

Recommendations (Oracle Health Facilities) This guidance provides consistent recommendations for proper pharmacy workload capture of inpatient and outpatient clinical pharmacy services for Oracle Health facilities.

Oracle Health facilities should assign all Clinical Pharmacy workload to the Stop Code corresponding with the Practice Area of the Encounter (e.g., 317, 32A, 420, 520). The Clinical Pharmacy Stop Code (160) should be very rarely used, only in the circumstances where another Practice Area is not more appropriate.

Pharmacists should enter their Charges using the Pharmacist Encounter Time Section and use Charge Details to set the Performing Location to the applicable “VA [Practice Area]” to ensure the Stop Codes are routed properly. Staff should not choose a Performing Location associated with their facility as that information is already known from the Encounter Location. Pharmacists who “Order” their CPT Codes instead of using the PowerForm will usually have an incorrect Stop Code associated. The Pharmacist

Encounter Time Section is in the PhARMD Tool PowerForm (and can be used irrespective of whether PhARMD Interventions are being documented), Ambulatory Anticoagulation PowerForm, Inpatient Anticoagulation PowerForm, Antimicrobial Stewardship PowerForm, Pharmacy to Manage Amikacin, Pharmacy to Manage Gentamicin, Pharmacy to Manage Tobramycin, and Pharmacy to Manage Vancomycin.

Using the Pharmacist Encounter Time Section allows the user to capture the actual minutes spent on the Encounter according to the modality. The PowerForm calculates the proper CPT codes based on the values entered by the staff. For instance, a pharmacist enters that they spent 65 minutes performing an Inpatient Chart Consult, the PowerForm will submit 1 x 98972 CPT Code but will also capture “65” as a discrete value that is extracted and used in workload and productivity reports.

Pharmaci…