Getting to Our Destination

By Tina Harrach Denetclaw, PharmD, APh, BCPS

 

Sometimes when my GPS announces, “You have arrived at your destination,” I look around and do not see my destination. Sometimes, it’s another block further, sometimes, it’s around the corner, or behind me. And, sometimes the GPS has taken me into the wrong neighborhood, altogether.

 

Something of this sort has happened with the 2016 California AB 1114, the first bill to authorize payment for pharmacists’ services as providers.

 

Passed in 2016, California AB 1114 authorizes Medi-Cal payments to pharmacists for providing immunizations, contraception, smoking cessation, naloxone, and travel medications services authorized by SB 493 and AB 1535. It states that the rate of reimbursement for pharmacist services shall be at 85 percent of the fee schedule for physician services under the Medi-Cal program and directs the California Department of Health Care Services (DHCS) to establish a fee schedule for the list of pharmacist services. Further, AB 1114 states pharmacists must be enrolled as ordering, referring, and prescribing (ORP) providers under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement under AB 1114.

 

This winter (three and a half years later), the Department of Health Care Services (DHCS) assigned the billing codes needed to implement AB 1114 as Current Procedural Terminology (CPT) codes 99201 for new patients, and 99212 for returning patients, who receive these services when provided by a pharmacist. See Table 1.

 

The assigned codes, however, do not allow sufficient time for pharmacists to meet the legal requirements for providing immunizations, contraception, smoking cessation, naloxone, and travel meds services. The assigned codes also do not reflect the level of complex decision-making involved in providing these services, nor the CPT codes that are used by physicians, nurse practitioners, and physician assistants to provide the same services.

 

For example, I happen to be one of the first California pharmacists to obtain certification in Smoking Cessation Counseling, as I received my certificate from the Washington State association about 1998, prior to California offering its own certification process. Limiting face-to-face time to 10 minutes for smoking cessation counseling is contrary to my training. Specifically, 10 minutes is not adequate for a pharmacist to meet the statute requirements for “Providing Tobacco Cessation Counseling and Furnishing Nicotine Replacement Therapy” including under the item, “Review the patient’s current tobacco use and past quit attempts.”

 

Furthermore, the statutes addressed in AB 1114 consistently include requiring pharmacists to obtain complete information, ask the patient a list of questions, provide detailed training for the patient, and answer patients’ questions. As I look over the required elements, especially for furnishing self-administered contraceptives, nicotine replacement products, and naloxone, I do not see that these services can be provided in a manner that meets the statutes within the 10 minutes of time allowed by the CPT codes.

 

If pharmacist services are not coded correctly, pharmacists and their employers will not be compensated for the time required to deliver the required elements of service to their patients Conversely, if pharmacists conform to the time limits of the CPT codes assigned and submit claims correctly for time spent as ordering, referring, and prescribing providers of these services, they likely will be in violation of the specific provisions authorizing pharmacists to provide these services.

 

What can pharmacists do to advocate adequate coding for pharmacist prescribing provider services?

Write to the administrators who determine the codes for implementing AB 1114! Their names and addresses are listed in Table 2. Template letters developed by the NCCCP Grassroots Advocacy Committee Steering Group can be found in Figures 1 and 2. These letters communicate that the assigned billing codes do not reflect the complexity of decision-making needed for providing services covered by AB 1114, nor do they allow sufficient time to meet the statute requirements for pharmacists providing those services. Pharmacists and student pharmacists are welcome to make use of these template letters to write to the administrators at DHCS who determine the CPT codes for AB 1114. Table 3 lists the CPT codes that CPhA has requested DHCS to assign for AB 1114, and also outlines regulations pharmacists must meet when providing services covered by AB 1114.

 

Individuals may add to the template letters provided in Figures 1 and 2 to convey personal experience and more detailed rationale. Experts in grassroots lobbying recommend letters be specific, polite, and professional, and that they be kept to one page (you may need to change font size slightly). Please to add your letter-writing to our tally so we can communicate our numbers to DHCS.

 

The NCCCP Grassroots Committee asks that letter-writers focus on the mismatch between the intention of the 2016 California Assembly Bill (AB) 1114 and the billing codes assigned to implement AB 1114. Our effort will have the most impact, and therefore the best chance of success, if we provide congruent messaging en masse.

 

With enough collective voices, we can lead DHCS in the right direction and institute fair compensation for our profession.

 

Table 1. DOCUMENTATION REQUIREMENTS FOR NEW- AND ESTABLISHED-PATIENT OFFICE VISITS

New patient
Code	History	Exam	Medical Decision-making	Typical face-to-face Time (minutes)
99201	Problem-focused	Problem-focused	Straightforward	10
99202	Expanded problem-focused	Expanded problem-focused	Straightforward	20
99203	Detailed	Detailed	Low	30
99204	Comprehensive	Comprehensive	Moderate	45
99205	Comprehensive	Comprehensive	High	60
*All three key components must be met.
Established Patient
Code	History	Exam	Medical Decision-making	Typical face-to-face Time (minutes)
99211	Not required	Not required	Not required	5
99212	Problem-focused	Problem-focused	Straightforward	10
99213	Expanded problem-focused	Expanded problem-focused	Low	15
99214	Detailed	Detailed	Moderate	25
99215	Comprehensive	Comprehensive	High	High 40
*Two of the three key components must be met.

 

Table 2. Administrators to address letters for advocating correct coding for AB 1114

DHCS	DHCS
Harry Hendrix Chief, Pharmacy Benefits Division Department of Health Care Services 1500 Capitol Ave. Sacramento, CA 95814	Mike Wofford, Pharm D. Chief, Pharmacy Policy Branch, Pharmacy Benefits Division Department of Health Care Services 1500 Capitol Ave. Sacramento, CA 95814

 

Table 3. AB1114 covered statutes with CPT codes recommended by CPhA to DHCS

Patient Activity/Presenting Problem	Patient Type	CPT Code	Medical Requirements of Pharmacist per Statute and/or Regulation
Furnishing Travel Medications pursuant to CCR 1746.5	New Established	99203 99214	Prior to furnishing travel medications, a pharmacist shall perform a good faith evaluation of the patient, including evaluation of the patient’s travel history using destination-specific travel criteria. The travel history must include all the information necessary for a risk assessment during pre-travel consultation, as identified in the CDC Yellow Book.
Furnishing Naloxone Hydrochloride pursuant to CCR 1746.3	New Established	99203 99214	Screen the potential recipient. Provide the recipient training in opioid overdose prevention, recognition, response, and administration of the antidote naloxone. The pharmacist shall provide the recipient with appropriate counseling and information on the product furnished, including dosing, effectiveness, adverse effects, storage conditions, shelf—life, and safety. The pharmacist shall provide the recipient with any informational resources on hand and/or referrals to appropriate resources if the recipient indicates interest in addiction treatment, recovery services, or medication disposal resources. The pharmacist shall answer any questions the recipient may have regarding naloxone hydrochloride. A pharmacist shall advise the recipient on how to choose the route of administration based on the formulation available, how well it can likely be administered, the setting, and local context. A pharmacist shall label the naloxone hydrochloride consistent with law and regulations. The pharmacist shall provide the recipient a copy of the current naloxone fact sheet approved by the Board of Pharmacy. Each naloxone hydrochloride product furnished by a pharmacist pursuant to this protocol shall be documented in a medication record for the naloxone recipient, and securely stored within the originating pharmacy or health care facility for a period of at least three years from the date of dispense.
Furnishing Self-administered Hormonal Contraception pursuant to 1746.1	New Established	99203 99214	When a patient requests self-administered hormonal contraception, the pharmacist shall complete the following steps: (A) Ask the patient to use and complete the self-screening tool; (B) Review the self-screening answers and clarify responses if needed; (C) Measure and record the patient’s seated blood pressure if combined hormonal contraceptives are requested or recommended; (D) Before furnishing self-administered hormonal contraception, the pharmacist shall ensure that the patient is appropriately trained. (E) When a self-administered hormonal contraceptive is furnished, the patient shall be provided with appropriate counseling and information on the product furnished, including: 1. Dosage; 2. Effectiveness; 3. Potential side effects; 4. Safety; 5. The importance of receiving recommended preventative health screenings; 6. That self-administered hormonal contraception does not protect against sexually transmitted infections (STIs). The pharmacist shall provide the patient with a self-screening tool containing the list of questions specified in this protocol. The pharmacist should provide the patient with a copy of a current, consumer-friendly, comprehensive birth control guide such as that created by the Food and Drug Administration (FDA). The pharmacist shall provide the patient with the FDA-required patient product information leaflet included in all self-administered hormonal contraception products, as required by Business and Professions Code Section 4052.3(c). The pharmacist should provide the patient with a copy of an administration-specific factsheet. The pharmacist shall notify the patient’s primary care provider of any drug(s) or device(s) furnished to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by that primary care provider. The pharmacist, in consultation with the patient, may select any hormonal contraceptive listed in the current version of the USMEC for individuals identified as Category 1 or 2. Each self-administered hormonal contraceptive furnished by a pharmacist pursuant to this protocol shall be documented in a patient medication record and securely stored within the originating pharmacy or health care facility for a period of at least three years from the date of dispense.
Initiating & Administering Immunizations pursuant to CCR 1746.4	New Established	99202 99213	A pharmacist shall notify each patient’s primary care provider of any vaccine administered to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by the primary care provider. A pharmacist shall report, in accordance with section 4052.8, subdivision (b)(3), of the Business and Professions Code, the information described in section 120440, subdivision (c), of the Health and Safety Code within 14 days of the administration of any vaccine. A pharmacist shall inform each patient or the patient’s guardian of immunization record sharing preferences, detailed in section 120440, subdivision (e), of the Health and Safety Code. For each vaccine administered by a pharmacist, a patient vaccine administration record shall be maintained in an automated data processing or manual record mod e such that the information required under section 300aa-25 of Title 42 of the United States Code is readily retrievable during the pharmacy or facility’s normal operating hours. A pharmacist shall provide each patient with a Board of Pharmacy Order of Adoption 16 CCR§ 1746.4 vaccine administration record, which fully documents the vaccines administered by the pharmacist.
Providing Tobacco Cessation Counseling and Furnishing Nicotine Replacement Therapy pursuant to CCR 1746.2	New Established	99203 99214	When a patient requests nicotine replacement therapy or other smoking cessation medication, or when a pharmacist in his or her professional judgment decides to initiate smoking cessation treatment and counseling, the pharmacist shall complete the following steps: Review the patient’s current tobacco use and past quit attempts. Ask the patient the following screening questions: (i) Are you pregnant or plan to become pregnant? (If yes, do not furnish and refer to an appropriate health care provider). (ii) Have you had a heart attack within the last 2 weeks? (If yes, furnish with caution and refer to an appropriate health care provider). (iii) Do you have any history of heart palpitations, irregular heartbeats, or have you been diagnosed with a serious arrhythmia? (If yes, furnish with caution and refer to an appropriate health care provider). (iv) Do you currently experience frequent chest pain or have you been diagnosed with unstable angina? (If yes, furnish with caution and refer to an appropriate health care provider). (v) Do you have any history of allergic rhinitis (e.g., nasal allergies)? (If yes, avoid nasal spray). (vi) Have you been diagnosed with temporal mandibular joint (TMJ) dysfunction? (If yes, avoid nicotine gum). The pharmacist shall review the instructions for use with every patient using a nicotine replacement product. Pharmacists should recommend the patient seek additional assistance for behavior change. The pharmacist shall answer any questions the patient may have regarding smoking cessation therapy and/or nicotine replacement products. The pharmacist, in consultation with the patient, may select any nicotine replacement product (alone or in combination) from the list of therapies specified in this protocol in the Table “Nicotine Replacement Therapy Medications for Smoking Cessation.” The pharmacist shall notify the patient’s primary care provider of any prescription drug(s) and/or device(s) furnished to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by that primary care provider. Each nicotine replacement product provided for smoking cessation and furnished by a pharmacist pursuant to this protocol shall be documented in a patient medication record and securely stored within the originating pharmacy or health care facility for a period of at least three years from the date of dispense. A patient medication record shall be maintained in an automated data processing or manual record mode such that the required information under title 16, sections 1717 and 1707.1 of the California Code of Regulations is readily retrievable during the pharmacy or facility’s normal operating hours.