Developing & managing a clinical practice

Question 1

Questions 1 and 2 pertain to the following case.
An accountable care organization (ACO) recently hired
you as the first clinical pharmacist for its internal medicine
clinic. Providers have been overwhelmed with the number
and complexity of the medication-related problems in their
patient population. They believe they need a pharmacist’s
skills; however, they are unclear about your role and service
and ask you to develop a proposal.
1. Which is the most important first step in preparing
your service proposal?
A. Do an external environmental scan to determine
which types of services others have provided to a
similar population.
B. Do an internal environmental scan to determine
which type of medication problems patients are
experiencing.
C. Determine the payer mix and current reimbursement
opportunities for pharmacist-provided
patient care services.
D. Focus on your specific training and strengths,
such as detailing your role and service in diabetes
patient care.

Answer 1

1. Answer: B
   The first step in planning any service is determining your
   organization’s needs. The optimal method is to perform
   what is termed an internal environmental scan, which is
   the collection of needed internal data that will identify
   important needs of the organization (Answer B is correct).
   Once these are identified, you can use other strategies to
   develop your proposal such that it becomes viable solution
   for the organization’s needs. Such strategies include
   the external environmental scan. To build the case for your
   services, you can use what is reported in the literature or
   provide examples of competitive organizations in your
   community that are already providing such services. You
   can also use your literature search to learn best practices
   and design your service to avoid barriers that others have
   identified and that may affect your services (Answer A
   is incorrect). Determining payer mix and reimbursement
   potential is crucial but is a secondary step after organizational
   needs are identified (Answer C is incorrect).
   Although you may be proud of your training and expertise,
   it may not mesh with the needs of the current job you are
   undertaking. Be confident that your training provides you
   with sufficient knowledge and self-directed learning skills
   to gain the necessary knowledge to develop services outside
   your comfort zone. If this development is well beyond
   your scope of knowledge, you may need to include hiring
   personnel with the desired training in your proposal. Never
   start a service that is not needed; it will be doomed to failure
   (Answer D is incorrect).

Question 2

2. You recognize that the success of your service depends
   on the efficiency of your workflow and how effectively
   it integrates with the workflow of other providers.
   Which is the optimal implementation strategy for your
   proposed daily workflow in the clinic?
   A. Perform all patient scheduling for the services you
   provide to prevent losing patients to follow-up.
   B. Use the clinic’s patient service representatives to
   perform patient scheduling services.
   C. Develop a rigid patient visit schedule set at 45
   minutes for new patient visits and 30 minutes for
   follow-up appointments.
   D. Establish a separate referral process from providers
   in the ACO to control your schedule.

Answer 2

2. Answer: B
   A common mistake made by pharmacists is to undertake
   duties that less-qualified support personnel can perform.
   Although it may seem reasonable to perform these duties
   when starting your clinic, it will be difficult to pass this
   work back to others as your practice becomes increasingly
   busy. It is wise to develop your workflow from the planning
   stages so that the work provided by the pharmacist is
   work that only you or another provider with similar skills
   can perform. Plan and negotiate using existing staff such
   as a medical assistants, schedulers, and front desk staff to
   perform functions and support they are already doing for
   others that you also will need. Provide them with guidelines
   and expectations for your services. They can make sure no
   patients are lost to follow-up if the expectation and process
   are clear (Answer A is incorrect; Answer B is correct). Rigid scheduling, an approach that health care has used for
   many years, is not optimal because it is not patient centered
   (Answer C is incorrect). Allowing flexibility in scheduling
   (e.g., building 10-minute catch-up slots or saving spots for
   daily unexpected needs) improves patient satisfaction and
   may even improve efficiency. Establishing a separate referral
   process is not a good choice because trying to create
   a new process only for your clinic requires your referral
   sources to learn and remember something different from
   what they are used to performing. This change in usual
   process would ultimately negatively affect your referrals
   (Answer D is incorrect).

Question 3

3. You are developing a Centers for Disease Control
   and Prevention (CDC)-recognized diabetes prevention
   program for your community pharmacy. When
   performing an analysis for strengths, weaknesses,
   opportunities, and threats (SWOT), which is the best
   opportunity for you to develop and create the program?
   A. Hiring a new pharmacist with a community
   postgraduate year one residency (PGY1) and an
   interest in diabetes management.
   B. Remodeling your pharmacy for immunizations
   with a private area to perform the service.
   C. Identifying that a large percentage of your patient
   population is of Southeast Asian descent, which
   is the fastest-growing population with diabetes in
   the United States.
   D. Reviewing billing codes that exist for this service,
   though you have not calculated whether this avenue
   for directly generating revenue will cover the
   program costs.

Answer 3

3. Answer: C
   Opportunities are situations and information that are
   external to your business or service that will support your
   initiative. That the population your pharmacy serves is
   primarily that for which data show is the fasting-growing
   population with diabetes suggests a need for and sustainability
   of your service (Answer C is correct). A strength of
   your proposed program is hiring a pharmacist with interest
   and competency in the prevention program. Strengths
   are internal criteria that support the program (Answer A is
   incorrect). The same is true for Answer B; it is a strength
   of your pharmacy that you have existing appropriate space
   (Answer B is incorrect). The availability of billing codes
   is a benefit but a questionable opportunity if costs are not
   fully covered (Answer D is incorrect).

Question 4

4. To produce the desired health outcomes, pharmacists
   can use a business tactic known as the balanced scorecard.
   Which group of organizational measures best
   reflects a balanced scorecard?

A. Percentage of providers trained in correct blood
pressure measurement technique; percentage of
patients with blood pressure values documented
at each visit; percentage of blood pressure values
less than 140/90 mm Hg; performance reimbursement
for meeting blood pressure value goals.
B. Number of errors made in computerized provider
order entry system; patient satisfaction scores;
hospital readmissions for heart failure; weight
documentation in chart.
C. Number of faxes versus electronic medical record
use for communication with the laboratory; A1C
values less than 8%; adherence rates to oral antihyperglycemic
medications; number of diabetes
visits per month per patient.
D. “Incident-to” evaluation and management
(E/M) code revenue; number of referrals for
smoking cessation; documentation of smoking
cessation education; maintenance of Board
Certified Ambulatory Care Pharmacist (BCACP)
credentials.

Answer 4

4. Answer: A
   Ensuring the providers are trained in correct blood pressure
   technique is a measure of your clinic structure,
   ensuring that blood pressure is documented at each visit
   is a process measure, achieving a blood pressure goal is
   an outcome, and knowing how that outcome influences
   the organization’s financial status is an important financial
   measure, thus meeting the four key elements of the
   balanced scorecard: structure, process, outcomes, and
   financial measurement (Answer A is correct). Answer B is
   lacking a structure measurement. The computerized provider
   order entry system would be a structure measure that
   could be used in this case to meet a balanced scorecard
   with the other measures listed. Answer C does not have a
   financial measure component, and Answer D does not have
   an outcome measure component.

Question 5

5. Your organization is moving toward value-based payment
   models and recently became part of the Medicare
   Shared Savings Program (MSSP). To sustain your services
   within the organization, you want to ensure that
   you are contributing to the quality measure set for this
   Medicare-based Alternative Payment Model (APM).
   Which measure set is best to review?
   A. Healthcare Effectiveness Data and Information
   Set (HEDIS) measures.
   B. Merit-Based Incentive Payment System (MIPS)
   measures.
   C. Interoperability measures.
   D. ACO measures.

Answer 5

5. Answer: D
   The MSSP was established by CMS under the ACA as a new
   approach to health care delivery to facilitate coordination
   and cooperation among providers to improve the quality
   of care for Medicare beneficiaries and reduce unnecessary
   costs. To participate in the MSSP, providers should either
   be an ACO or participate in an ACO. Participants must
   report on the ACO quality measures established by CMS
   (Answer D is correct). The MIPS measurement of interoperability
   is for Medicare Part B, which is a FFS model
   (Answers B and C are incorrect). The HEDIS measure set
   is for commercial plans (Answer A is incorrect).

Question 6

6. Your practice is growing and needs another pharmacist
   practitioner. Your physician partners have clearly
   stated their desire for the new hire to have the same
   level of skills as you in order for them to be comfortable
   in extending the collaborative practice agreement
   (CPA) to that practitioner. The risk management team
   is also concerned with consistency and the same
   standard of practice and skill. To mimic what the
   organization uses to ensure highly competent physicians,
   nurse practitioners, and physician assistants,
   you develop a credentialing and privileging program
   for patient care pharmacists. Which tactic is best to use to assure your organization that the best hire has
   been made?
   A. BCACP credentials.
   B. Postgraduate year two (PGY2) training.
   C. Peer review of services at 90 days.
   D. Medication therapy management (MTM) training
   certification.

Answer 6

6. Answer: C
   Although BCACP status, PGY2 training, and MTM certification
   may all be desired credentials, they within
   themselves will not guarantee that the new hire meets the
   needs of your organization or be at the same skill level
   as you, the organization’s current patient care pharmacist
   (Answers A, B, and D are incorrect). The necessary degree
   of trust for that individual will develop on the basis of his
   or her performance, thus making peer review of services
   the best option for building the needed trust and confidence
   (Answer C is correct).

Question 7

7. You are a pharmacy director of a community hospital
   that lost 3% of its Medicare revenue this past year
   because of the readmission penalty. To rectify this
   problem, the hospital has a strategic plan to improve
   its ambulatory care presence. You have pharmacists
   currently in the ambulatory clinic attached to the hospital;
   however, you have not pursued billing for their
   services. You believe the current pharmacists’ services
   will meet the intent of the new strategic plan, but you
   also know that the ability to generate revenue directly
   will be a key component in sustaining these services.
   Which group of codes will be most beneficial to pursue
   in sustaining and potentially growing these services?
   A. 99605–99607 MTM service codes.
   B. 99211–99215 incident-to E/M codes.
   C. Ambulatory Payment Classification (APC) 5012,
   G0463 facility fee codes.
   D. APC 5011, Current Procedural Terminology
   (CPT) 99490 chronic care management (CCM)
   codes.

Answer 7

7. Answer: C
   Under HOPPS, all mid-level practitioners who are employees
   of the hospital and meet incident-to rules bill the
   same facility fee code. The current revenue for that code
   is a reasonable reimbursement (Answer C is correct).
   Codes for MTM are not currently recognized or payable
   under Medicare Part B (Answer A is incorrect), nor are
   the incident-to E/M codes submitted by pharmacists currently
   recognized under HOPPS (Answer B is incorrect).
   The CCM codes can only be used for patients who meet
   the criteria established by CMS (Answer D is incorrect).
   In addition, the reimbursement for CCM codes is currently
   less than that for the facility fee code.

Question 8

8. Which billing opportunity is currently best for a physician
   group to use to generate revenue for patient
   services performed by pharmacists under general
   supervision?
   A. MTM codes.
   B. CCM codes.
   C. Incident-to codes.
   D. Wellness visits.

Answer 8

8. Answer: B
   Medicare relaxed the incident-to rules of direct supervision
   for CCM and TCM services that can be performed
   by auxiliary personnel within their scope of practice
   (includes pharmacists) to bill these particular codes.
   General supervision is thought to be sufficient because
   the Medicare-approved provider in these cases would be
   setting, sharing, and reviewing patients’ plans of care,
   thus providing general supervision (Answer B is correct).
   Incident-to E/M codes and AWVs are incorrect because they require direct supervision (Answers C and D are
   incorrect). Medication therapy management is not a recognized
   billing code under Medicare Part B (Answer A is
   incorrect).

Question 9

Practice Case
1. You recently completed a residency with an ambulatory care focus and have been hired by the pharmacy department
of a health system to start ambulatory services. The health system has an outpatient clinic with primary care
and medical specialty services. Historically, the pharmacy department has only provided inpatient services to the
organization. The health system’s goal is to expand into ambulatory care in preparation for value-based payment
contracts. The director of pharmacy asks you to develop a plan regarding which service would be best to start
with: transitional care, MTM, polypharmacy management, or specialty services. Which is your best first step?
A. Review the literature on successful practices for each service.
B. Pursue transitional care services because you had a residency rotation on these.
C. Choose specialty services because of the associated use of high-cost medications.
D. Perform a gap analysis to determine which services are most needed in the organization.

Answer 9

1. Answer: D
   The best first step is to use the skills you gained during
   residency to collect the necessary information to determine
   what is most needed by your organization and what
   can be resolved with pharmacist services (Answer D is
   correct). Performing this gap analysis and developing your
   service while keeping your organization’s needs in mind
   provide the best chance for your program to be approved
   and continue to be successful. Review of the literature is
   an important step; however, it would be a second step after
   the optimal service is determined on the basis of need and
   resources (Answer A is incorrect). Your residency training
   should provide you with the critical thinking skills and
   understanding of how to start a new service, and although
   it would be convenient to perform a service with which you
   have experience, that service may not meet the organization’s
   needs (Answer B is incorrect). Although managing
   high-cost specialty medications is needed by many organizations,
   it may not be needed by your organization (Answer
   C is incorrect).

Question 10

2. You have been providing clinical pharmacy services in an antithrombosis clinic in your organization for 2 years
   and would like to expand your services. You routinely document vital signs and have noticed that blood pressure
   values are above goal for many clinic patients; however, you have not had time to address this medication-related
   issue for most patients. At a recent clinic staff meeting, measures where the practice was not performing well were
   presented. Blood pressure control was one of the measures. You would like to develop a new pharmacist-led blood
   pressure management service and present the proposal to your clinic administrator. Which information will be
   most important to obtain from an external environmental scan to use in your initial proposal?
   A. Literature that supports positive financial and clinical patient outcomes from pharmacist services in blood
   pressure management.
   B. Advice solicited from an e-mail list of ambulatory care pharmacists providing blood pressure management
   services.
   C. Established practice standards specifically for pharmacists in blood pressure management.
   D. The advertising brochure from the clinic 2 miles away detailing that it is part of the Million Hearts initiative.

Answer 10

2. Answer: A
   The most important information to obtain from an external
   environmental scan is supportive literature because evidence
   is strong for positive outcomes and the value of using
   pharmacists in blood pressure management (Answer A is
   correct). Answers B, C, and D might provide information
   that would support your expansion of services; however,
   with the strength of evidence, Answer A would best justify
   the expansion of pharmacy services.

Question 11

3. You have been hired as an assistant professor focused on ambulatory care at a new college of pharmacy. The college
   has secured a new practice site in a family practice office that is reengineering its practice to align with the
   Medicare and commercial ACO programs in which it is now participating. The service wants you to begin seeing
   individuals with diabetes because the practice needs to improve its quality measures for both Medicare and commercial
   payer contracts. Which best describes the optimal referral process to provide your service with the most
   appropriate patients to affect the stated quality measures?
   A. Referral by a physician for each qualified patient.
   B. Automatic referral for patients with A1C 9% or greater.
   C. Offer for patients to choose to participate in the pharmacist-provided patient care service.
   D. Automatic referral only for individuals with diabetes insured through the commercial ACO.

Answer 11

3. Answer: B
   It is best to have a group of patients identified and scheduled
   when the doors of your service open. This approach
   accomplishes several goals, including efficiency with no
   excessive downtime, whereas use of other approaches may
   cause other employees in the service to question what you
   are doing. In addition, this approach allows you to begin
   generating outcomes sooner that sufficiently demonstrate
   your value (Answer B is correct). Waiting for referrals by
   a physician is problematic, primarily because of the following:
   in their busy schedule, physicians may not often
   think about referring their patients; they may have incentives
   not to refer, depending on the billing incentives in
   the ACO; and they may not initially trust in the pharmacist’s
   skill set (Answer A is incorrect). Asking patients to
   make another appointment with a provider with whom they are not familiar or for a reason they may not understand
   can be problematic (Answer C is incorrect). It is difficult
   for any organization to treat one payer population by providing
   services different from other payer organizations.
   This approach is also problematic with Medicare if the
   Medicare population is not receiving the same service as
   other populations for financial reasons; therefore, this process
   is not recommended (Answer D is incorrect).

Question 12

4. You are creating your referral template for a comprehensive medication management clinic available to all providers
   in the medical group. Because most of your patients will likely be older, supervision will be provided by the
   Medicare Part B providers (e.g., physicians, nurse practitioners) in the primary care clinic to meet the Medicare
   rules for reimbursement. Which is most critical to include in your referral form?
   A. Provider generating the referral.
   B. Pharmacist for whom the provider is directing the referral.
   C. Reason for referral.
   D. Expectations of referral.

Answer 12

4. Answer: C
   A standard in Medicare billing, especially in the FFS billing
   that eligible providers use for delegated services such
   as pharmacist-provided patient care services, is the concept
   of medical necessity. It requires the billing provider to document
   a statement of medical necessity or the reason why
   the patient must see the provider to whom he or she was
   referred. Although this can be documented in the assessment
   and plan of the note of the referring provider, its
   inclusion in a referral form ensures that this step is documented.
   Payers such as Medicare will audit billed services.
   Not having this information may constitute fraud and usually
   results in any payment for the referred service being
   returned to the payer. This consideration makes the reason
   for referral the most important item that is nonnegotiable
   when creating your referral template or process (Answer
   C is correct). The points in Answers A, B, and D are also
   important for optimal coordination and communication.

Question 13

5. Both in your proposal and after its approval, you will need a timeline for establishing your program. Which is the
   optimal time interval from approval to seeing first patients for your service (in months)?
   A. 3.
   B. 6.
   C. 12.
   D. 18.

Answer 13

5. Answer: B
   Although reasonable timelines will vary depending on
   when investment revenue is available or whether any construction
   is required, in general, you will want to take
   enough time to make sure you have addressed all considerations
   so that, when your clinic opens, it can focus primarily
   on patients and less on management issues. You also do not
   want to have excessive delays because, to administrators,
   “time is money.” The ideal time is 6 months (Answer B
   is correct). Three months is likely too short to address all
   the items required in developing and operating a service
   (Answer A is incorrect). Going beyond 12 months is likely
   too long and may discourage your stakeholders from supporting
   your clinic (Answers C and D are incorrect).

Question 14

6. You have a well-established heart failure clinic and have consistently decreased readmission rates for heart failure.
   Many of your patients have comorbid diabetes, and you have also begun managing this condition through
   recommendations to clinic providers. However, treating patients with diabetes is slowing the clinic workflow
   because of needed approval for any medical decision-making you perform for patients with comorbid diabetes.
   Which is the best course of action to resolve this inefficiency?
   A. Adjust your schedule to spend one day in the endocrinologist’s office to further develop professional
   relationships.
   B. Work with your medical group to expand your CPA to include diabetes medication management.
   C. Hire an additional pharmacist to focus solely on diabetes management for these patients.
   D. Establish an electronic-based communication system to allow for faster communication.

Answer 14

6. Answer: B
   Answer B is correct. An initial CPA is often narrow in
   scope. It often requires time to build trust in your competency
   and skill with your team and supervising providers. As that trust progresses, your team will refer more patients
   with a broader range of conditions. Expanding your scope
   of practice in a CPA is the quickest and simplest fix.
   Adjusting your schedule is an option if you have an endocrinologist’s
   supervision to manage diabetes; however,
   many of the patients you see routinely may be treated by
   primary care and not need that level of specialist care or
   cost (Answer A is incorrect). Hiring an additional pharmacist
   is an option, though costly and unnecessary if you can
   handle the workload (Answer C is incorrect). Establishing
   an electronic-based communication system is not the root
   cause of the problem you are facing (Answer D is incorrect).

Question 15

7. An audit by the compliance officer results in a notification that you cannot use incident-to billing for the patients
   for whom you are managing diabetes and heart failure with sodium-glucose cotransporter-2 inhibitors. Your current
   CPA and protocol have not been updated since 2015. Which is the most likely reason for the result of this
   audit?
   A. Not within the pharmacist’s state scope of practice.
   B. Change in Medicare payment rules.
   C. Outdated CPA.
   D. Not outlined in your policy and procedure.

Answer 15

7. Answer: C
   Answer C is correct. As new therapies and updated guidelines
   are available, it is important to review your CPAs to
   ensure the allowed practices are current and fully reflect
   the pharmacist’s services. If CPAs are not reviewed at
   least yearly, they may quickly become outdated. Because
   Medicare billing requirements include that services provided
   by auxiliary staff must be within their scope of
   practice, a CPA that does not cover a provided service
   results in that service not being within the scope of practice
   (i.e., a state pharmacy practice act allows such services only
   under a CPA). In such situations under a Medicare audit,
   CMS may require that all payments for such services be
   returned. Answer A is incorrect because if sodium-glucose
   cotransporter-2 inhibitors were part of the CPA, it would
   be within the state scope of practice. Answer B is currently
   incorrect because Medicare allows reimbursement for auxiliary
   services if they are within the pharmacist’s scope of
   practice. Medicare can change the rules at any time, which
   stresses the importance of staying current on billing rules
   and regulations. Answer D is incorrect because billing
   rules and regulations are not governed by organizational
   policy and procedures.

Question 16

8. The physician group for whom you practice has secured an alternative payment contract with a large commercial
   insurer for both Medicare Advantage and commercial beneficiaries. The contract is a set payment per month per
   patient, with the potential for bonuses on the basis of set outcome measures. Which best describes this valuebased
   payment model?
   A. FFS with pay for performance.
   B. Bundled payment model.
   C. Risk-sharing model.
   D. Global payment model.

Answer 16

8. Answer: D
   Answer D is correct. In global payment, the provider
   receives a set fee per member for a designated time and
   then earns additional revenue on the basis of quality performance.
   In the FFS model, there is no standard payment
   per beneficiary (Answer A is incorrect). In the FFS model,
   a reimbursement for service is provided, with the potential
   for additional reimbursement on the basis of quality
   measures. Bundled payments are a set payment for a particular
   service or diagnosis for a member (e.g., pregnancy,
   hip replacement). Bundled payments are not per-member
   per-time period (Answer B is incorrect). Because the basis of the risk-sharing model is to share the risk and losses for
   not achieving quality measures or cost goals, Answer C is
   incorrect.

Question 17

9. You practice within a medical group accountable for MIPS measure reporting for Medicare payment. The organization’s
   goal is to achieve a score in the calendar year that will result in bonus Medicare payments. In addition
   to clinical quality measures, which set of MIPS measures is best to focus on to successfully contribute to the
   group’s MIPS score?
   A. Develop an opioid education program for patients and providers.
   B. Measure patient satisfaction with your services.
   C. Focus on decreasing hospitalizations for the patients within your service.
   D. Ensure that your data are included in the group’s quality registry.

Answer 17

9. Answer: C
   In MIPS, four categories contribute to the total score:
   clinical quality measures, practice improvement activities,
   advancing care information, and cost. Cost of care is
   increasing in importance, which currently accounts for 20%
   of the total score and will increase to 30% in 2024. Cost is
   determined on the basis of the total per capita cost, which
   includes total Medicare Part A and B costs for a beneficiary;
   thus, total per capita costs include costs from hospitalizations.
   Pharmacist-provided patient care services have
   clearly decreased hospitalizations; therefore, this strategy
   would best assist the practice with its MIPS score (Answer
   C is correct). Developing an opioid education program is
   included in improvement activities; however, improvement
   activities contribute to only 15% of the total score and are
   not as effective as decreasing costs and contributing to the
   cost of the MIPS score (Answer A is incorrect). Measuring
   patient satisfaction has received increased CMS attention;
   however, practice CAHPS (Consumer Assessment of
   Healthcare Providers and Systems) scores do not directly
   include pharmacist services and would not be as effective
   as reducing hospitalization costs (Answer B is incorrect).
   Although use of a registry is associated with collecting
   data on clinical quality measures, a registry cannot discern
   attribution of your work as a clinical pharmacist; nevertheless,
   you would want your data to be included in the quality
   registry (Answer D is incorrect).

Question 18

10. You have been instructed by your director to meet with your organization’s compliance officer to discuss the
    opportunity to use incident-to codes to directly generate revenue for the patient care services you provide to the
    clinic. In preparing for this meeting, you want to make sure you understand the terminology and rules for these
    codes. Which factor regarding the characteristics and considerations for using incident-to codes is most important
    to ensure the types of service you provide are eligible for reimbursement?
    A. They fall under American Medical Association (AMA) CPT level 1 codes.
    B. They require documentation of E/M of a condition.
    C. They can only be used for established patients.
    D. They require direct supervision for you to provide the services.

Answer 18

10. Answer: B
    Answer B is correct. The most important aspects for which
    you are fully responsible are documenting your visit and
    ensuring that it meets the requirements of E/M of a medical
    condition, which is what is paid for under Medicare Part
    B. You must follow the E/M guidance as set forth by CMS.
    Although incident-to codes fall under AMA CPT level
    1 codes and you should know the terminology, it is less
    important for you to understand the CPT level for effective
    use of the codes (Answer A is incorrect). In addition,
    incident-to codes can only be used for established patients,
    meaning you cannot see a patient before the patient sees
    the eligible Part B provider. Eligible Part B providers must
    establish the plan of care and the medical necessity for your
    service incident-to their services. Although this is important
    for you to know, it is most important for the clinic and
    other providers to know this progression before a patient is referred to you or placed on your schedule (Answer C
    is incorrect). Incident-to requires immediate supervision,
    which is also important for you to know but is more important
    for whoever manages the clinic operations to know to
    ensure a supervising provider is present when you are providing
    your services (Answer D is incorrect).

Question 19

11. You recently completed a community residency practice and have been hired by an independent pharmacy that
    wants to start building services beyond MTM through Medicare Part D. Your practice is in a rural community
    where there is an older adult population and a high incidence of common chronic conditions such as hypertension,
    type 2 diabetes, chronic obstructive pulmonary disease, obesity, and smoking. You have a good relationship with
    the regional hospital and the family practice physician in town. The pharmacy owner has added a stipulation that
    there must be revenue to cover the expense of the service (e.g., staffing, promotion, and materials needed). Which
    service is best to initiate?
    A. Medicare Diabetes Prevention Program (MDPP).
    B. Transitional care management (TCM).
    C. Chronic care management (CCM).
    D. Annual wellness visits (AWVs).

Answer 19

11. Answer: A
    The MDPP is not a large undertaking, and it would allow
    you to better understand how best to incorporate a clinical
    program into the pharmacy workflow. The program
    can also be created and billed directly by the pharmacy.
    Starting this program would give you experience in managing
    revenue for a clinical program (Answer A is correct).
    Although TCM and CCM are also good choices, they are
    complex (Answers B and C are incorrect). In addition to
    their complexity, the rules for these programs require contracting
    with either the hospital or the physicians in the
    area because only eligible Medicare Part B providers can
    bill for the services. It may be best to start with a smaller
    self-sustaining and manageable program. Depending on
    which services the hospital has and its readmission rates,
    TCM may be a reasonable alternative. Because AWVs
    require direct supervision, they can only be performed in a
    physician’s office (Answer D is incorrect). Although community
    pharmacists are assisting physicians by staffing
    this program in a physician office, this approach does pull
    that resource away from the pharmacy for a shift and may
    not be optimal in an independent pharmacy.