Developing and Managing Clinical Practice

Question 1

_ is the comparison of what is presently occurring with what is desired to occur

Answer 1

gap analysis

Question 2

What are the best standards to reference for clinical pharmacist practice best practices?

Answer 2

ACCP Standards of Practice for clinical pharmacists

Question 3

SWOT analysis stands for _, _, _, _

Answer 3

Strengths, weaknesses, opportunities, threats

Question 4

2 different types of direct revenue generation are:
- _ (FFS)

-_ - pay for performance

Answer 4

traditional fee-for-service; value-based payment models

Question 5

Timeline for establishing a practice:
Month 1:
- perform _ (2 part)
-draft _ and vision statements and goals
-identify important _
-review state and federal scope of practice and _ rules
-perform _ analysis

Answer 5

internal and external environmental scan; mission; stakeholders; payment; SWOT

Question 6

2 types of value-based payment models (a type of ) are:
- model -payment for services aligned with quality measures through incentives
-global payment -achieve quality benchmarks and get paid per patient per month or year

Answer 6

alternative payment models (APM); pay-for-performance

Question 7

Measuring the quality of your program:
Balanced Scorecard (FSPP)
1. _
2. _
3. _
4. _

Answer 7

financial; structure; processes; patients

Question 8

Measuring the quality of your program:
Balanced Scorecard
Examples of FINANCIAL metrics: clinic growth (i.e. # of referrals), return on _, cost _, value/cost ratio, funding/billing

Answer 8

investment; avoidance or savings

Question 9

Measuring the quality of your program:
Balanced Scorecard
examples of STRUCTURE metrics:
trained staff; _ tools, communication systems, workload, employee _

Answer 9

technological; satisfaction/retention

Question 10

Measuring the quality of your program:
Balanced Scorecard
examples of PROCESS metrics:
_ rate, _, care processes/task performance, timeliness

Answer 10

error; documentation

Question 11

Measuring the quality of your program:
Balanced Scorecard
examples of PATIENTS metrics:
clinical _, satisfaction, care experiences

Answer 11

outcomes

Question 12

Sources for Quality Measures:
_-related organizations:
- _ (AHRQ)
-pharmacy quality alliance (PQA)
-national quality forum (NQF)
- _ (UDS) for FQHCs
- _

Answer 12

government; agency for healthcare research and quality; universal data set; center for medicare and medicaid (CMS)

Question 13

Sources for Quality Measures:
_ organizations:
-_ (NCQA) - _ and _ accreditation
-center for pharmacy practice accreditation (CPPA)
-utilization review accreditation commission (URAC)
-joint commision

Answer 13

accreditation; national committee for quality assurance; HEDIS; ACO and PCMH

Question 14

Sources for Quality Measures:
NCQA (an accreditation org) develops _ measures. CMS uses these to determine _

Answer 14

HEDIS; star ratings

Question 15

Sources for Quality Measures:
medicare part A: _ (HRRP)

Answer 15

hospital readmissions reduction program

Question 16

Sources for Quality Measures:
Medicare Part B: _ (QPP)

Answer 16

quality payment program

Question 17

Federal government:
quality measurement and payment on the basis of reported quality measures is the cornerstone of _ and the changes in reimbursement for Medicare Part B

Answer 17

MACRA

Question 18

Balanced scorecard:
- ensuring # providers are trained in correct blood pressure technique = _ measure
- ensuring BP is documented at each visit = _ measure
-achieving BP goal = _ measure (or patients)
- performance reimbursement for meeting BP value goals = _ measure

Answer 18

structure; process; patients (outcomes); financial

Question 19

Sources for Quality Measures:
Medicare Part C and D (medicare advantage and prescription program): _

Answer 19

STAR Measures

Question 20

Sources for Quality Measures:
Commercial Payers: _

Answer 20

HEDIS measures- healthcare effectiveness and Data information set

Question 21

Sources for Quality Measures:
Medicaid:
- _ measure set
- _ measures

Answer 21

adult core; state-specific

Question 22

MSSP stands for _. To participate in the MSSP, participants must report on the _ quality measures established by _

Answer 22

medicare shared savings program; ACO; CMS

Question 23

the _ measure set is for commercial plans

Answer 23

HEDIS

Question 24

HOPPS stands for _. Under HOPPS all mid-level practitioners (hospital employees) who meet incident to rules bill the same _. This billing code is _ and must meet incident to requirements

Answer 24

hospital outpatient prospective payment system; facility fee code; G0463

Question 25

For billing incident to services: -physician office-based requires _ of eligible physician or nonphysician provider -hospital outpatient services require _ of an eligibe physician or nonphysician provider

Answer 25

direct supervision (must be w/in same office space); general supervision (presence not required)

Question 26

Which billing opportunity is currently best for a physician group to use to generate revenue for patient services performed by pharmacists under general supervision?

Answer 26

CCM codes

Question 27

99211 is an incident to billing code and requires _. Whereas, 99490 is _ billing code and only requires _

Answer 27

direct supervision; CCM; general supervision

Question 28

_ is an annual document released by the CMS that outlines policy and operation updates for medicare advantage (part C) and part D plans for the upcoming year

Answer 28

CMS call letter

Question 29

Level 2 codes are for products, supplies and services not contained within CPT. for these we stick to the _

Answer 29

G codes

Question 30

Incident to is billed under the supervising providers _

Answer 30

NPI number

Question 31

For office-based Indicent to billing: -direct supervision -_ must exist between auxillary personnel and eligible provider

Answer 31

financial relationship

Question 32

for hospital outpatient incident to billing: -general supervision (evidence of supervisory communication via sharing a plan of care) -financial relationship must exist between auxilliary personnel and the _ as an employee, leased employee, or independent contractor

Answer 32

hospital

Question 33

Hospital outpatient revenue generating opportunities: Facility fee: APC code _ + HCPCS code _

Answer 33

5012; G0463

Question 34

office/outpatient E/M: time spent with auxiliary personnel does not _

Answer 34

contribute to total time

Question 35

TCM codes: 99495 and 99496 requires communication (can be by digital means) with the patient or caregiver within _ of discharge

Answer 35

2 business days.

Question 36

For Chronic care management (CCM): -time is per month -patients with _ chronic conditions expected to last at least 12 months -99490: _ 20 minutes -99439: _ 20 minutes -complex CCM code 99487 for first _ minutes, each additional 30 minutes: 99489

Answer 36

≥ 2; first; each additional; 60 minutes

Question 37

CCM requirements: 1. 1st visit by _ provider 2. patient _ must be documented 3. 24/7 access to team members 4. ongoing assessment of care plan 5. care plan captured electronically Supervision requirements: may furnish the _ services incident to an eligible provider under general supervision

Answer 37

eligible billing provider; consent; non face to face

Question 38

MTM codes are _ - _ (numbers)

Answer 38

99605; 99607

Question 39

MTM medicare part D requirements: -_ interactive face-to-face CMR

Answer 39

annual

Question 40

MTM codes: _: new patient, initial 15 minutes _: established patient, initial 15 minutes _: for each additional 15 minutes (used only in addition to the above)

Answer 40

99605; 99606; 99607

Question 41

>12 months after IPPE: initial AWV _ be performed by auxilliary personnel under _ supervision Code: G0438 - same for subsequent AWVs: code G0439

Answer 41

can; direct

Question 42

Diabetes self-management training (DSMT) (G0108 individual; G0109 group) program must have: -accreditation from ADCES or _ -partnership with an eligible medicare part B provider -requires _ for DSMT "diabetes services order form"

Answer 42

ADA; written referral

Question 43

Selecting your quality measures: - _ -_ -_

Answer 43

meaningfulness; feasibility; actionable