Low hanging fruit

Hopefully everyone had a good holiday break, and maybe even the chance to curl up with a good book…or better, with the Federal Register!  Yes, you heard that right, the Federal appleRegister from 2016 has a number of positive developments in areas that are or will soon be ‘ripe’ for pharmacist intervention.  Notices and rulemaking for Medicare are published by CMS in the Federal Register. These notices are often accompanied by CMS’ responses to comments received on proposed rulemaking as well as some interesting background data.  So let’s look at what CMS considers important (i.e. what they are willing to pay for).  First, they recognize that medication misadventures often result in costly adverse effects including ED visits and hospitalizations.  They recognized MTM as needed (Ref 1), and when it was clear that it wasn’t being used as often as they wanted, they expanded the criteria to qualify more patients for MTM.  Realizing that medication misadventures were more likely during care transitions, CMS decided to reimburse for Transitional Care Management (CPT 99495, 99496) that included Medication Reconciliation. (Ref 2) With CMS’ announced aggressive plan to move to a system of more value-based reimbursement, new payment models were recently release as MACRA-MIPS (Ref 3), and medication reconciliation was a key component for the Merit-based Incentive Payment System (Ref 3, see pgs 77225 and 77230).

Switching gears to a key condition recognized by CMS, diabetes, it is clear that they value Diabetes Self Management Education (CPT G0108, G0109), and that they have increased the reimbursement for provision of that service. (4) Recently, CMS has announced that it will reimburse diabetes prevention in the proposed Medicare Diabetes Prevention Program (Ref 5, see section III.J)  The preliminary structure proposal is in Ref 5, and establishes how you can be prepared for the final rulemaking in 2017, and implementation in 2018.  In this document you can find links to the proposed standards and to the proposed curriculum developed by CDC. This is a must read if you want to be prepared to offer this service!

Finally, CMS has not only established reimbursement for Chronic Care Management (CPT 99490), but updated their rules with new codes for more complex patients who are involved in CCM (CPT 99487-99489) so that the reimbursement could better reflect the amount of work involved with CCM in highly complex patients (Ref 5, see section E.4 and Table 11).  As most of you already know, CCM can be provided to patients with 2 or more chronic diseases, and thus nearly all your patients with diabetes would qualify.

It is clear that medications, diabetes and chronic care are not only on the CMS’ radar screen, but they are addressing concerns related to expansion of these services as well as augmenting reimbursement.  Members of the ACCP Endocrine & Metabolism PRN are particularly well positioned to take advantage of many of these services!

At the 2016 ACCP Annual Meeting in October, a session discussing TCM and CCM was poorly attended, yet just down the hall a session on PCSK-9 inhibitors was packed.  While being the local guru on pharmacodynamics of PCSK-9 inhibitors may bring personal satisfaction, providing services such as TCM, CCM, DSMT, and soon MDPP brings revenue.  We are fighting for recognition as ‘providers’, and in any fight, you are lucky when the other guy telegraphs his moves.  CMS is not telegraphing, they are shouting it from the rooftops, yet only a few ACCP members are doing any of these services.  My bias is obvious, if you want to be recognized as ‘providers’, then start providing what your customer wants!

  1. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Public Law 108-173. December 8, 2003. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-108publ173/content-detail.html. [accessed 12/27/2016]
  2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf [accessed 12/27/2016]
  3. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician- Focused Payment Models. Federal Register / Vol. 81, No. 214 / Friday, November 4, 2016 / Rules and Regulations. https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm [accessed 12/27/2016]
  4. Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf [accessed 12/27/2016]
  5. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. https://www.federalregister.gov/documents/2016/11/15/2016-26668/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions [accessed 12/27/2016]
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