Pharmacy-Based Bone Density Testing · Pharmacy-Based Bone Density Testing Question 1 Which of the following is a feasible site for BMD screening services? A. Physician office B

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PharmacyPharmacy--BasedBasedBone Density Bone Density

TestingTesting

Question 1Question 1

Which of the following is a feasible site for Which of the following is a feasible site for BMD screening services?BMD screening services?

A.A. Physician officePhysician officeB.B. PharmacyPharmacyC.C. Health clubHealth clubD.D. All the above All the above


What is the standard recognized health care What is the standard recognized health care billing form?billing form?

A.A. CMS 1500 CMS 1500 B.B. CMS 1400CMS 1400C.C. Care Claim FormCare Claim FormD.D. ICDICD--99

This education program is a product/publication of the National Community Pharmacists Association (NCPA). Copyright © 2006. All rights reserved.

Any reproduction, photocopying, storage or transmission by magnetic or electronic means without the expressed written consent of NIPCO/NCPA and the payment of appropriate fees is strictly prohibited by law.

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Which type of BMD device is generally used Which type of BMD device is generally used for screening purposes in a community for screening purposes in a community pharmacy?pharmacy?

A.A. Central DXACentral DXAB.B. Peripheral DXAPeripheral DXAC.C. Ultrasound Ultrasound D.D. B & CB & C


What are patients typically paying for a BMD What are patients typically paying for a BMD screening test?screening test?

A.A. $5 to $15$5 to $15B.B. $10 to $35 $10 to $35 C.C. $25 to $50$25 to $50D.D. Nobody pays Nobody pays


What is the value in a business plan?What is the value in a business plan?

A.A. Assessment of expenses and revenues Assessment of expenses and revenues B.B. Keeps consultants in businessKeeps consultants in businessC.C. Necessary to get third party Necessary to get third party

reimbursementreimbursementD.D. All the aboveAll the above



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InstructionsInstructions

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Learning ObjectivesLearning Objectives

List three reasons why pharmacists should consider List three reasons why pharmacists should consider offering Bone Mass Density (BMD) testingoffering Bone Mass Density (BMD) testingDescribe the statement of medical necessity and its role Describe the statement of medical necessity and its role in billing for osteoporosis care servicesin billing for osteoporosis care servicesDefine the billing codes necessary to complete a CMS Define the billing codes necessary to complete a CMS 1500 form1500 formDevelop a business plan for an osteoporosis screening Develop a business plan for an osteoporosis screening and management servicesand management servicesDescribe the basic procedure for operating an ultrasound Describe the basic procedure for operating an ultrasound BMD testing deviceBMD testing deviceDiscuss the necessity for Quality Control when operating Discuss the necessity for Quality Control when operating BMD testing devicesBMD testing devices

At the conclusion of this program, participants should be able to:

Lindsey Stephens, Lindsey Stephens, R.PhR.Ph., FACA., FACA

BS in Pharmacy from Drake University College of BS in Pharmacy from Drake University College of PharmacyPharmacyCurrently the Director of Professional Services for Currently the Director of Professional Services for Medicine Shoppe International & Medicap Medicine Shoppe International & Medicap Pharmacies, Inc. Pharmacies, Inc. Spoken nationally on osteoporosis numerous timesSpoken nationally on osteoporosis numerous timesPreviously has served on the Proctor & Gamble Previously has served on the Proctor & Gamble Osteoporosis Advisory Committee and the Iowa Osteoporosis Advisory Committee and the Iowa Osteoporosis Coalition Board of DirectorsOsteoporosis Coalition Board of Directors



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Planning Planning ConsiderationsConsiderations

Why?Why?

Increase customer traffic into pharmacyIncrease customer traffic into pharmacyCompanion sales opportunityCompanion sales opportunity–– Vitamins, DME Vitamins, DME

New revenue sourceNew revenue sourceOffer disease management servicesOffer disease management servicesProfessional imageProfessional imageProfessionally and personally rewardingProfessionally and personally rewarding

Planning ConsiderationsPlanning ConsiderationsCompetitionCompetitionTesting venues Testing venues Technology selectionTechnology selectionStaff trainingStaff trainingScreening criteriaScreening criteriaLogistics Logistics Advertising & promotionAdvertising & promotionInterpreting results Interpreting results



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Competitive AnalysisCompetitive AnalysisIdentify where people currently Identify where people currently receive these services in your receive these services in your community community –– Physician officePhysician office–– Other pharmacies Other pharmacies –– Local hospital Local hospital –– Health fairs Health fairs

Competitive AnalysisCompetitive Analysis

Evaluate each siteEvaluate each site–– Services offeredServices offered–– Geographic area served Geographic area served –– Marketing approachesMarketing approaches–– StrengthsStrengths–– Weaknesses Weaknesses

Local HospitalsLocal HospitalsUse peripheral screenings toUse peripheral screenings to–– Refer to physician partnersRefer to physician partners–– Feed downstream services (Feed downstream services (ieie. DXA scans). DXA scans)–– Help enhance community prevention imageHelp enhance community prevention image

FeesFees–– Often at little or no cost to consumerOften at little or no cost to consumer–– Used as a “loss leader”Used as a “loss leader”



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Planning ConsiderationsPlanning ConsiderationsCompetitionCompetition

Testing venues Testing venues Technology selectionTechnology selectionStaff trainingStaff trainingScreening criteriaScreening criteriaLogistics Logistics Advertising & promotionAdvertising & promotionInterpreting results Interpreting results

Testing VenuesTesting VenuesOnOn--SiteSite–– Your pharmacyYour pharmacy

OffOff--SiteSite–– Area physician clinicsArea physician clinics–– Local hospitalsLocal hospitals–– Health clubsHealth clubs–– Community centersCommunity centers–– Places of worshipPlaces of worship–– SchoolsSchools–– EmployersEmployers–– Health fairsHealth fairs

Testing VenuesTesting VenuesConsiderations when evaluating a siteConsiderations when evaluating a site–– Potential patient populationsPotential patient populations

»» DemographicsDemographics»» Size of potential poolSize of potential pool

–– Cost Cost »» Labor Labor »» Transportation to and fromTransportation to and from»» SuppliesSupplies

–– Suitability of space/area for testingSuitability of space/area for testing–– If you have been contacted by a site to conduct BMD If you have been contacted by a site to conduct BMD

testing and the size of the patient pool or demographics testing and the size of the patient pool or demographics are questionable, and you are unsure about the financial are questionable, and you are unsure about the financial viability of an event, you could require a flat fee from viability of an event, you could require a flat fee from the testing venue in order to assure you a financially the testing venue in order to assure you a financially sound eventsound event



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Planning ConsiderationsPlanning ConsiderationsCompetitionCompetitionTesting venues Testing venues

Technology selectionTechnology selectionStaff trainingStaff trainingScreening criteriaScreening criteriaLogistics Logistics Advertising & promotionAdvertising & promotionInterpreting results Interpreting results

Technology SelectionTechnology Selection

RegulationsRegulationsPortabilityPortabilityEase of useEase of use

Technology SelectionTechnology SelectionRegulatory issues for XRegulatory issues for X--ray based ray based devicesdevices–– Machine registration and feesMachine registration and fees

»» Vary from state to stateVary from state to state»» Usually required upon installationUsually required upon installation»» Limited registration periods (1Limited registration periods (1--3 years)3 years)



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Regulatory issues for XRegulatory issues for X--ray based ray based devices devices –– Operator requirementsOperator requirements

»» Range from none to requiring a Certified Range from none to requiring a Certified Radiological Technician (CRT) to having a Radiological Technician (CRT) to having a permit requiring specific certification and permit requiring specific certification and training of technician operator to operate a training of technician operator to operate a BMD machineBMD machine


Regulatory issues for XRegulatory issues for X--ray ray based devices based devices –– Inspection and renewalInspection and renewal

»» PostPost--installation surveys may be installation surveys may be required required

»» ReRe--inspection at set intervals may inspection at set intervals may »» also be mandatedalso be mandated

Technology SelectionTechnology SelectionRegulatory issues for XRegulatory issues for X--ray based ray based devices devices –– Shielding requirementsShielding requirements

»» Generally there are no specific shielding Generally there are no specific shielding requirementsrequirements

»» Some states do specify shielding requirementSome states do specify shielding requirement



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Technology SelectionTechnology SelectionRegulatory issues for XRegulatory issues for X--ray based ray based devices devices –– Machine transportation across state linesMachine transportation across state lines

»» Some states require notice be given to a state Some states require notice be given to a state agency before transporting xagency before transporting x--ray equipment ray equipment into the stateinto the state


Regulatory issues for all devicesRegulatory issues for all devices–– BMD screening equipment is registered by the BMD screening equipment is registered by the

FDA as a prescriptive device. Therefore, you FDA as a prescriptive device. Therefore, you MUST either have a prescription, a statement of MUST either have a prescription, a statement of medical necessity from a physician, a standing medical necessity from a physician, a standing order signed by a physician prior to conducting order signed by a physician prior to conducting screenings OR contact the patient’s primary screenings OR contact the patient’s primary care physician for approvalcare physician for approval


Size and portability of the Size and portability of the device device –– How much space necessary How much space necessary

to operate the device?to operate the device?–– Is weight and ease of Is weight and ease of

moving an issue for offmoving an issue for off--site site testing? testing?



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Ease of useEase of use–– Steps involved in Quality Control Steps involved in Quality Control

(QC) and screening(QC) and screening–– Procedure for body positioningProcedure for body positioning

»»Proper body placement is keyProper body placement is key–– Use of water baths or gelsUse of water baths or gels–– How much “undressing” is requiredHow much “undressing” is required


Quality Control Quality Control ProcedureProcedure–– Ease of performingEase of performing–– Frequency Frequency

»» Every dayEvery day»» Every weekEvery week»» OtherOther

Any day a screening will be Any day a screening will be conducted and anytime the conducted and anytime the machine has been transportedmachine has been transported

–– Cost to completeCost to complete

Technology SelectionTechnology SelectionCost per testCost per test–– Employees’ time (RPh vs. tech)Employees’ time (RPh vs. tech)–– Supplies (gel, wipes, printer paper, etc)Supplies (gel, wipes, printer paper, etc)–– QC testingQC testing–– Transportation Transportation –– Amortized equipment cost Amortized equipment cost –– OverheadOverhead



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Technology SelectionTechnology SelectionActual time to complete entire patient Actual time to complete entire patient interactioninteraction–– Patient prepPatient prep

»» UndressingUndressing»» Applying gelApplying gel»» Appropriate positioningAppropriate positioning»» Clean up after testClean up after test»» RedressingRedressing

–– Testing procedure from start to getting a Testing procedure from start to getting a printed reportprinted report

–– Patient consultationPatient consultation–– DocumentationDocumentation

Technology SelectionTechnology SelectionCompany supportCompany support–– What installation services do they provide? What installation services do they provide? –– What is the training process?What is the training process?–– How do they handle malfunctioning How do they handle malfunctioning

equipment?equipment?–– Where is the closest service facility? Where is the closest service facility? –– What is the turn around time for replacement What is the turn around time for replacement

machines?machines?–– Do they have a call center?Do they have a call center?–– What are their hours of operation?What are their hours of operation?–– What is the average response time to What is the average response time to

answering calls and average time to SOLVE answering calls and average time to SOLVE problems?problems?

–– Do they provide patient educational materials Do they provide patient educational materials and promotional materials to assist you?and promotional materials to assist you?

Peripheral XPeripheral X--Ray Based Ray Based EquipmentEquipment

AbsorptiometryAbsorptiometry –– handhandAbsorptiometryAbsorptiometry –– heel and forearmheel and forearmAbsorptiometryAbsorptiometry –– forearmforearmAbsorptiometryAbsorptiometry -- heelheel



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AbsorptiometryAbsorptiometry -- HandHandMethod:Method: dual energy xdual energy x--ray ray absorptiometryabsorptiometrySite:Site: handhandRadiation Dose:Radiation Dose: 0.3 0.3 mRemmRemScan Time:Scan Time: 30 sec30 secReference Pop:Reference Pop: females of various ethnic females of various ethnic

backgrounds & Caucasian males backgrounds & Caucasian males Components:Components: scanner with microcomputer, scanner with microcomputer,

optional printeroptional printerWeight:Weight: 70 lb70 lbDry systemDry system

AbsorptiometryAbsorptiometry –– Heel and Heel and ForearmForearm

Method:Method: dualdual--energy xenergy x--ray ray absorptiometryabsorptiometrySite:Site: heel and forearmheel and forearmRadiation DoseRadiation Dose: 20 : 20 mRemmRemScan Time:Scan Time: 5 sec5 secReference Pop:Reference Pop: female & male Caucasiansfemale & male CaucasiansComponentsComponents: scanner, computer, printer: scanner, computer, printerWeightWeight = 70 lbs= 70 lbsDry systemDry system



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AbsorptiometryAbsorptiometry -- ForearmForearm

Method:Method: dual energy xdual energy x--ray ray absorptiometryabsorptiometrySite:Site: forearmforearmRadiation Dose:Radiation Dose: < 3 < 3 mRemmRemScan Time:Scan Time: 5 min5 minReference Pop:Reference Pop: males and females of various males and females of various

ethnic groupsethnic groupsComponents:Components: scanner, computer, printer scanner, computer, printer Weight =Weight = 59 lbs59 lbsDry systemDry system



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AbsorptiometryAbsorptiometry -- HeelHeel

Method:Method: dualdual--energy xenergy x--ray ray absorptiometryabsorptiometrySite:Site: heelheelRadiation Dose:Radiation Dose: < 0.2 < 0.2 mRemmRemScan Time:Scan Time: 15 sec15 secReference Pop:Reference Pop: males and females of various males and females of various

ethnic groups ethnic groups Components:Components: scanner, control console, scanner, control console,

printerprinterWeightWeight = 64 lbs= 64 lbsDry systemDry system

UltrasoundUltrasound--Based EquipmentBased Equipment

Ultrasound Ultrasound -- HeelHeel



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Ultrasound Ultrasound -- HeelHeelMethod:Method: ultrasoundultrasoundScreening Site:Screening Site: heelheelRadiation Dose:Radiation Dose: nonenoneScan Time:Scan Time: ~1 min~1 minComponents:Components: scanner scanner

with microprocessor with microprocessor & printer& printer

Weight:Weight: 22 lbs22 lbsUses a water based gelUses a water based gel

Ultrasound Ultrasound -- HeelHeel

Method:Method: ultrasound ultrasound Site:Site: heelheelRadiation Dose:Radiation Dose:

nonenoneScan Time:Scan Time: 1 min1 minComponents:Components:

scanner, builtscanner, built--in in microprocessor and microprocessor and printerprinter

lb

Insert Video HereInsert Video Here



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Planning ConsiderationsPlanning Considerations

CompetitionCompetitionTesting venues Testing venues Technology selectionTechnology selection

Staff trainingStaff trainingScreening criteriaScreening criteriaLogistics Logistics Advertising & promotionAdvertising & promotionInterpreting results Interpreting results

Planning ConsiderationsPlanning Considerations

When training your staff on the technology selected to When training your staff on the technology selected to screen patients be sure to educate them on:screen patients be sure to educate them on:–– How it worksHow it works–– The precision & validity of the test compared to a DXA and otherThe precision & validity of the test compared to a DXA and other

peripheral devicesperipheral devices–– The use of the machine for screenings The use of the machine for screenings –– The use of the machine for monitoringThe use of the machine for monitoring–– Review the stepReview the step--byby--step instructions on technical use for the step instructions on technical use for the

equipmentequipment–– The legal environment in your state associated with offering BMDThe legal environment in your state associated with offering BMD

screenings and assessing fracture risk of patients screened withscreenings and assessing fracture risk of patients screened without out actually providing a diagnosisactually providing a diagnosis

Staff TrainingStaff TrainingAssigning responsibilityAssigning responsibility–– Economic & skill level considerationEconomic & skill level consideration

Topics to addressTopics to address–– Clinical knowledgeClinical knowledge–– Device operation & maintenanceDevice operation & maintenance–– Overall operation of service (policy & Overall operation of service (policy &

procedures)procedures)Initial training & ongoing updatesInitial training & ongoing updates



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Staff TrainingStaff Training

Must ensure accuracy of testing Must ensure accuracy of testing resultsresults–– Proper operation of deviceProper operation of device–– Ongoing QC Ongoing QC –– Periodic evaluation of staffPeriodic evaluation of staff

Planning ConsiderationsPlanning ConsiderationsCompetitionCompetitionTesting venues Testing venues Technology selectionTechnology selectionStaff trainingStaff training

Screening criteriaScreening criteriaLogisticsLogisticsAdvertising & promotionAdvertising & promotionInterpreting results Interpreting results

Screening CriteriaScreening Criteria

Testing Guidelines according to the NOFTesting Guidelines according to the NOF–– All postmenopausal women <65 years old who have 1 or more All postmenopausal women <65 years old who have 1 or more

additional risk factors for osteoporosisadditional risk factors for osteoporosis–– All women >65 years old regardless of additional risk factorsAll women >65 years old regardless of additional risk factors–– Postmenopausal women who present with fractures (to confirm Postmenopausal women who present with fractures (to confirm

disease and determine disease severity)disease and determine disease severity)–– Women who are considering treatment for osteoporosisWomen who are considering treatment for osteoporosis–– Women who have been on HRT for prolonged periodsWomen who have been on HRT for prolonged periods

Refer to the Bone Density Consent Form in the Osteoporosis Care Refer to the Bone Density Consent Form in the Osteoporosis Care Toolkit to see a risk factor checklistToolkit to see a risk factor checklist



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Peripheral Screenings in Men Peripheral Screenings in Men and Ethnicitiesand Ethnicities

DXADXA–– Some reference populations for men and Some reference populations for men and

ethnicitiesethnicities–– Consensus is to avoid the use of peripheral Consensus is to avoid the use of peripheral

screening in menscreening in menUltrasoundUltrasound–– Not FDA approvedNot FDA approved–– No reference populationsNo reference populations

»» Difficult to compareDifficult to compare

Planning ConsiderationsPlanning ConsiderationsCompetitionCompetitionTesting venues Testing venues Technology selectionTechnology selectionStaff trainingStaff trainingScreening criteriaScreening criteria

LogisticsLogisticsAdvertising & promotionAdvertising & promotionInterpreting results Interpreting results

LogisticsLogistics

Applies to inApplies to in--store and offstore and off--site site operationsoperations–– Space requirementsSpace requirements–– Adequate and qualified personnelAdequate and qualified personnel–– Hours of operationHours of operation–– Appointment schedulingAppointment scheduling–– Consent forms and necessary documentsConsent forms and necessary documents–– Adequate supplies & equipmentAdequate supplies & equipment



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Planning ConsiderationsPlanning ConsiderationsCompetitionCompetitionTesting venues Testing venues Technology selectionTechnology selectionStaff trainingStaff trainingScreening criteriaScreening criteriaLogistics Logistics

Advertising & promotionAdvertising & promotionInterpreting results Interpreting results

Advertising and PromotionAdvertising and PromotionInIn--store promotionstore promotion–– Bag stuffer, banner, personalized letters to Bag stuffer, banner, personalized letters to

select patients select patients

AdvertisingAdvertising–– Newspaper ads, radio, cable television, direct Newspaper ads, radio, cable television, direct

mail (Valmail (Val--Pak)Pak)

Detailing referral sourcesDetailing referral sources–– MCOsMCOs, hospitals, employers, physician , hospitals, employers, physician

practicespractices

Advertising and PromotionAdvertising and Promotion

ConsiderationsConsiderations–– Hitting target audienceHitting target audience–– Cost effectivenessCost effectiveness–– Address why patients should have BMD testingAddress why patients should have BMD testing–– Garner support of physician opinion leader in Garner support of physician opinion leader in

community community –– Community partnershipsCommunity partnerships



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PartnersPartners

Pharmaceutical representativesPharmaceutical representatives–– Detailing physicians and having them Detailing physicians and having them

partner with youpartner with you–– Providing financial assistance for Providing financial assistance for

screenings in physician offices and the screenings in physician offices and the communitycommunity

PartnersPartners

Pharmacy wholesalers Pharmacy wholesalers -- national and national and regional pharmacy organizationsregional pharmacy organizations–– Disease management programsDisease management programs

»» Bone Health programsBone Health programs

–– Financial incentive for program start upFinancial incentive for program start up–– Discounts on equipment and suppliesDiscounts on equipment and supplies–– Marketing and advertising materialsMarketing and advertising materials

Planning ConsiderationsPlanning ConsiderationsCompetitionCompetitionTesting venues Testing venues Technology selectionTechnology selectionStaff trainingStaff trainingScreening criteriaScreening criteriaLogistics Logistics Advertising & promotionAdvertising & promotion

Interpreting results Interpreting results



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Interpreting Test ResultsInterpreting Test Results

Only physicians can interpret test Only physicians can interpret test resultsresults

Explaining Screening ResultsExplaining Screening Results

FemaleFemaleAge 31Age 31TT--scorescoreZZ--scorescore% Young Adult% Young Adult% Age Matched% Age Matched

Osteoporosis Screening & Education in Osteoporosis Screening & Education in Community Pharmacies Using a Team ApproachCommunity Pharmacies Using a Team Approach

Pharmacotherapy 2005;25:379Pharmacotherapy 2005;25:379--386386

Description of serviceDescription of service–– Patients were referred by MD to RPh located at Patients were referred by MD to RPh located at

Walgreen's PharmacyWalgreen's Pharmacy–– Obtained medical & drug historyObtained medical & drug history–– Performed heel ultrasound scanPerformed heel ultrasound scan–– Educated patient on results, standard dietary Educated patient on results, standard dietary

recommendations & lifestyle modificationsrecommendations & lifestyle modifications–– Results from patients with low BMD scores Results from patients with low BMD scores

forwarded to referring MDforwarded to referring MD



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Osteoporosis Screening & Education in Osteoporosis Screening & Education in Community Pharmacies Using a Team ApproachCommunity Pharmacies Using a Team Approach

Pharmacotherapy 2005;25:379Pharmacotherapy 2005;25:379--386386

ResultsResults–– 97 patients enrolled 97 patients enrolled

»» 46% had T46% had T--score < score < --1 to > 1 to > --2.52.5»» 9% had T9% had T--score score << --2.52.5

–– Patient satisfactionPatient satisfaction»» 94% found the program made them feel better about 94% found the program made them feel better about

how they take care of themselveshow they take care of themselves»» 87% felt more in control of their health87% felt more in control of their health»» 96% would recommend the service to others 96% would recommend the service to others

PharmacistPharmacist--run run TeriparatideTeriparatideClinicClinic

Am J HealthAm J Health--SystSyst PharmPharm 2003:60;22472003:60;2247--22492249

Purpose: Purpose: to ensure appropriate & safe useto ensure appropriate & safe useServices:Services:

Chart review to ensure patient was Chart review to ensure patient was evaluated for possible secondary causes & evaluated for possible secondary causes & no contraindications no contraindications Patient education on preventive measures, Patient education on preventive measures, proper drug administrationproper drug administrationPhone follow up in one weekPhone follow up in one weekRTC at one monthRTC at one month

Pharmacists are NOT Pharmacists are NOT diagnosing osteoporosis. We diagnosing osteoporosis. We are helping to identify those are helping to identify those potentially at risk.potentially at risk.

KEYPOINTS



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Reimbursement IssuesReimbursement Issues

CLAIM

CLAIM

CLAIM

Sources of ReimbursementSources of ReimbursementPatient selfPatient self--paypay–– CashCash–– HSAsHSAs

Contractual arrangementsContractual arrangements–– Sources:Sources: MCOsMCOs

EmployersEmployersPBMsPBMsPhysiciansPhysiciansPharmaceutical companiesPharmaceutical companies

–– Type of contracts:Type of contracts: Fee for serviceFee for serviceCapitationCapitationRisk sharingRisk sharing

Billing thirdBilling third--party payersparty payers

ReimbursementReimbursement

For BMD screeningFor BMD screeningFor consultative For consultative serviceservice



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Establish a Fee ScheduleEstablish a Fee ScheduleDetermine cost of doing Determine cost of doing businessbusiness––TimeTime––OverheadOverhead

Reimbursement for BMD Reimbursement for BMD ScreeningScreening

SelfSelf--paypay–– Fee range $10Fee range $10--$35 for these types of screenings $35 for these types of screenings

Insurance other than MedicareInsurance other than Medicare–– Coverage varies depending upon policyCoverage varies depending upon policy–– Changes in state mandates may extend coverage to Changes in state mandates may extend coverage to

more individualsmore individuals

Reimbursement for BMD Reimbursement for BMD TestingTesting

MedicareMedicare–– An amendment went into effect July 1, 1998 which requires An amendment went into effect July 1, 1998 which requires

Medicare to cover bone mass measurement in select Medicare to cover bone mass measurement in select populations:populations:

»» EstrogenEstrogen--deficient women at risk for osteoporosis deficient women at risk for osteoporosis »» Vertebral abnormalities demonstrated by xVertebral abnormalities demonstrated by x--rayray»» Primary hyperparathyroidismPrimary hyperparathyroidism»» LongLong--term term glucocorticoidglucocorticoid therapytherapy»» Efficacy monitoring for approved osteoporosis drugsEfficacy monitoring for approved osteoporosis drugs

–– One test every two years One test every two years –– some exceptionssome exceptions

MedicaidMedicaid–– Coverage varies by stateCoverage varies by state



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Reimbursement for BMD Reimbursement for BMD TestingTesting

MedicareMedicare–– Independent Diagnostic Testing Facility (IDTF)Independent Diagnostic Testing Facility (IDTF)

»» Entity independent of a hospital or physician’s officeEntity independent of a hospital or physician’s office»» Performed by licensed, certified nonPerformed by licensed, certified non--physician personnel under physician personnel under

appropriate physician supervisionappropriate physician supervision»» Fixed location, mobile entity, or individual nonFixed location, mobile entity, or individual non--physician physician

practitionerpractitioner»» Physician oversight necessary and evidence proficiencyPhysician oversight necessary and evidence proficiency»» Individual physician order neededIndividual physician order needed»» Billed using CMS 1500 form using common CPT & ICDBilled using CMS 1500 form using common CPT & ICD--9 codes 9 codes

and specialty code 47 for claims processingand specialty code 47 for claims processing

Reimbursement for Bone Reimbursement for Bone Health ConsultationsHealth Consultations

SelfSelf--paypay–– Fee range $15Fee range $15--$60 for 15$60 for 15--30 minute consultation 30 minute consultation

sessionssessionsInsurance coverage other than MedicareInsurance coverage other than Medicare–– Coverage varies depending upon policyCoverage varies depending upon policy

MedicareMedicare–– The MMA may offer a new opportunity for MTM The MMA may offer a new opportunity for MTM

reimbursement for these services reimbursement for these services

Standardize Your FeesStandardize Your Fees

Must charge all patients the same price for Must charge all patients the same price for the same servicethe same service

Fee Schedule



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Information Needed to Information Needed to Complete CMS 1500 for Complete CMS 1500 for Service ReimbursementService Reimbursement

Patient’s medical Patient’s medical insurance insurance informationinformationICDICD--9 9 code(scode(s))CPT codeCPT codeProvider IDProvider ID

ICDICD--9 Codes9 Codes

International Classification of DiseaseInternational Classification of DiseaseCodes based on disease, injuries, and Codes based on disease, injuries, and patient encounterpatient encounterV code V code –– V77.9 screening for unspecified V77.9 screening for unspecified endocrine, nutritional, metabolic and endocrine, nutritional, metabolic and immunity disordersimmunity disordersPhysician diagnosis codePhysician diagnosis codeDocument sourceDocument source

CPT CodesCPT CodesCurrent Procedural TerminologyCurrent Procedural TerminologyDescribes professional services, procedures, Describes professional services, procedures, and testsand tests–– If a pharmacist is providing MTMS, e.g., for If a pharmacist is providing MTMS, e.g., for

osteoporosis medication monitoring, then use new osteoporosis medication monitoring, then use new MTMS codes. For complete information on MTMS MTMS codes. For complete information on MTMS codes, go to codes, go to www.pstac.orgwww.pstac.org

Must have supporting documentation of Must have supporting documentation of services providedservices provided



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Selecting a CPT CodeSelecting a CPT Code

ScreeningsScreenings–– Selected depending upon device usedSelected depending upon device used

ConsultationsConsultations–– Use appropriate MTM codeUse appropriate MTM code

Documentation MUST support code choiceDocumentation MUST support code choice–– SOAP note: SOAP note:

»» Patient Name, DOB, description of service provided, time spent wPatient Name, DOB, description of service provided, time spent with ith patient providing service, test results, assessment of the patipatient providing service, test results, assessment of the patient, ent, pharmacist’s findings and recommended followpharmacist’s findings and recommended follow--upup

Submitting A Claim Submitting A Claim Provider NumberProvider Number

National Provider Identifier (NPI) or other National Provider Identifier (NPI) or other health plan provider identifierhealth plan provider identifier–– Identifies the rendering providerIdentifies the rendering provider–– Needed on CMS 1500 formNeeded on CMS 1500 form–– NPI is effective May 23, 2007NPI is effective May 23, 2007–– CMS website address: CMS website address:

www.cms.hhs.gov/providers/npiwww.cms.hhs.gov/providers/npi

Submitting the ClaimSubmitting the ClaimStatement of medical necessityStatement of medical necessityCMS 1500 formCMS 1500 formDocumentation of services Documentation of services



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Submitting A Claim Submitting A Claim Statement of Medical NecessityStatement of Medical NecessityMay be necessary to be reimbursedMay be necessary to be reimbursedPhysician referral formPhysician referral formProvider ID and ICDProvider ID and ICD--9 code9 code

Submitting A Claim Submitting A Claim Claims FormsClaims Forms

CMS 1500CMS 1500–– The standard recognized health care billing form The standard recognized health care billing form –– Universal billing form for lab tests, procedures, Universal billing form for lab tests, procedures,

professional services, equipment professional services, equipment –– Can be used if fewer than 10 FTEs Can be used if fewer than 10 FTEs –– Electronic claims format is beginning to be widely Electronic claims format is beginning to be widely

available to pharmacies available to pharmacies

DocumentationDocumentationMUST document the level of care MUST document the level of care providedprovidedUse a recognized, systematic methodUse a recognized, systematic method“If it is not documented, you did not do “If it is not documented, you did not do it.”it.”SOAP noteSOAP note



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ConsiderationsConsiderations

Contact insurance company prior to Contact insurance company prior to submitting claim for approval submitting claim for approval Use the terms “counseling” or “self Use the terms “counseling” or “self management” rather than management” rather than “education”“education”Be consistent and persistentBe consistent and persistent

If billing insurance companies, If billing insurance companies, allow them at least 45 days to allow them at least 45 days to make payment. Then call to make payment. Then call to inquire about status of claim.inquire about status of claim.

ResourcesResourcesLocal officesLocal offices–– CMSCMS–– Part B carrierPart B carrier–– Part D PDPPart D PDP

Reimbursement guides and newsletters Reimbursement guides and newsletters Billing servicesBilling servicesBilling softwareBilling softwareNIPCO: 1NIPCO: 1--800800--544544--74477447



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Business Plan Business Plan DevelopmentDevelopment

The What and Why of Business The What and Why of Business PlansPlans

Detailed description of future business goals Detailed description of future business goals and a means of achieving those goalsand a means of achieving those goalsAssessment of expenses and revenuesAssessment of expenses and revenuesRoad map to keep you on courseRoad map to keep you on course

Business PlanBusiness Plan

Setting goalsSetting goals–– For patientsFor patients–– For our pharmacyFor our pharmacy

Identifying all steps necessary for Identifying all steps necessary for successful implementation and ongoing successful implementation and ongoing operation of programoperation of program–– Creating an action plan and timelineCreating an action plan and timeline–– Establishing costs (startEstablishing costs (start--up and ongoing)up and ongoing)



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Action Plans and Action Plans and Implementation TimelinesImplementation Timelines

Develop two action plans with timelinesDevelop two action plans with timelines–– StartStart--up/one time only action itemsup/one time only action items–– Ongoing operationsOngoing operations

»» Setting a screening scheduleSetting a screening schedule

Determining Osteoporosis Services Determining Osteoporosis Services OfferedOffered

ExamplesExamples–– Screenings onlyScreenings only–– Management serviceManagement service–– Prevention servicePrevention service

GoalsGoals



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Example Goals of ServiceExample Goals of ServiceFor patientsFor patients–– Enhance patient understanding of osteoporosis Enhance patient understanding of osteoporosis –– Improve rate of adherence with treatmentImprove rate of adherence with treatment–– Ensure optimal drug, dose, and regimen selectionEnsure optimal drug, dose, and regimen selection–– Identify patients at risk for osteoporosis and encourage Identify patients at risk for osteoporosis and encourage

followfollow--up careup careFor our pharmacyFor our pharmacy–– Engage all interested members of the pharmacy team to Engage all interested members of the pharmacy team to

assist in development, implementation, and assist in development, implementation, and administrationadministration

–– Generate projected revenue and profits in years one and Generate projected revenue and profits in years one and two two

–– Increase profits in subsequent years and diversify Increase profits in subsequent years and diversify service offeringservice offering

Crafting the Business PlanCrafting the Business Plan

Regulatory considerations Regulatory considerations Site development and preparation Site development and preparation In store logisticsIn store logisticsAdvertising and promotionAdvertising and promotionReimbursement Reimbursement Return on investment analysisReturn on investment analysisEvaluation of Evaluation of service(sservice(s))Ongoing operationsOngoing operations

Application Exercise #5Application Exercise #5

Click here to access PDF of the Module 5 Application Exercise - Information for Reimbursement and Business Planning. Please print this tool prior to continuing with the program.



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Application Exercise #5 Application Exercise #5 Stuart’s PharmacyStuart’s Pharmacy

Located in a medical office complexLocated in a medical office complex2,000 square foot pharmacy2,000 square foot pharmacyCompetes with chain, supermarket and discount Competes with chain, supermarket and discount pharmacies and has succeeded by offering pharmacies and has succeeded by offering friendly, knowledgeable servicefriendly, knowledgeable serviceCurrently fills 2,000 prescriptions per week Currently fills 2,000 prescriptions per week Hours MonHours Mon--Fri 9 to 6 and Sat. 9 to 2Fri 9 to 6 and Sat. 9 to 2Staff: one fullStaff: one full--time pharmacist (Stuart Jones time pharmacist (Stuart Jones ––owner), one partowner), one part--time pharmacist (Grace), two time pharmacist (Grace), two fullfull--time pharmacy technicians and two fulltime pharmacy technicians and two full--time time pharmacy cashierspharmacy cashiers

Stuart’s PharmacyStuart’s Pharmacy

Review business planReview business planIs the pharmacy going to be able to meet the Is the pharmacy going to be able to meet the set goals?set goals?Is anything missing?Is anything missing?What changes can made in the business plan What changes can made in the business plan to improve the return on investment? to improve the return on investment?

Business Plan for Stuart’s Business Plan for Stuart’s PharmacyPharmacy

Services PlannedServices Planned–– Osteoporosis screeningOsteoporosis screening

Goals of ServiceGoals of Service–– Enhance the health service image of the pharmacy Enhance the health service image of the pharmacy –– Identify patients at risk for osteoporosisIdentify patients at risk for osteoporosis–– Break even within two yearsBreak even within two years–– Create a structure so that services for other disease Create a structure so that services for other disease

states may be added states may be added –– Provide new and challenging professional experience Provide new and challenging professional experience

for the staff for the staff Target start dateTarget start date–– 12 weeks from now 12 weeks from now



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Site Development and PreparationSite Development and Preparation

Remodeling - None at this time

StuartStuart$12,000$12,0004 weeks4 weeksEquipment - Research, select, and purchase BMD machine

Furniture - Have chairs and table to use

Location for screenings - In store only at this time

GraceGrace$250/ $250/ $100 $100

10 weeks10 weeksSupplies - Gel, wipes, paper towels, patient education materials

Assigned Assigned ToTo

CostCostTimelineTimeline

InIn--Store LogisticsStore Logistics

Stuart 4 x $60/hr

2 weeks Pharmacist staffing -4hrs/month RPh time

Grace$20010 weeks Training staff pharmacist on osteoporosis

Stuart None 10 weeksTraining of employees on use of machine

Grace$50/ $25

6 weeks Patient care documentation system - Will use paper system

StuartNone 10 weeksTraining of employees on program



Advertising and PromotionAdvertising and Promotion

Grace$20010 weeksPhysician Physician –– Direct mail Direct mail Targets: Targets: James, King, Stevens, James, King, Stevens, LewisLewis

Grace$50 8 weeks Patient Patient –– InIn--store identification store identification Use brochure as bag stuffer Use brochure as bag stuffer

Grace$5008 weeks InIn--store store Brochure, banner, counter Brochure, banner, counter card, yard sign card, yard sign





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ReimbursementReimbursement

Method for filing and tracking claims (billing software or service)

StuartNone12 weeksDetermine method for collecting payment from patient

Done$25Determine screening fees



FinancialsFinancials

StuartNone12 weeksTracking revenues and service delivered

DoneNoneReturn on investment analysis



Evaluation of ServicesEvaluation of Services

Other

Patient goals

StuartNone12 weeks and beyond

Revenue targetsExpenses and revenues tracked continually and evaluated annually





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Ongoing OperationsOngoing Operations

Grace$80012 weeks and beyond

Advertising and promotionContinue with in-store identification and direct mail to physicians add some newspaper advertising

Grace12 weeks and beyond

Scheduling screening events

GraceNone12 weeks and beyond

BMD machine calibration

GraceNone12 weeks and beyond

Policy and procedure manualTo be developed and kept up-to-date



Return on Investment AnalysisReturn on Investment Analysis

0.0012,000.00BMD machine

$5,245.00$16,330.00Total Expenses800.00750.00Advertising/promotion

0.00400.00Pharmacist training 100.00250.00Other supplies

25.0050.00Documentation supplies4,320.002,880.00Additional staffing

Year TwoYear OneExpenses

Return on Investment AnalysisReturn on Investment Analysis

Direct Revenue2,400.00 1,200.00Prescription Revenue

$3,011.00($11,362.00)Profit8,256.004,968.00Total Revenue

456.00168.005% of screening customers will buy calcium supplements

Indirect Revenue5,400.003,600.00Screening Fees

Year TwoYear One



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Analysis of the Business PlanAnalysis of the Business PlanIs the pharmacy going to be able to meet the Is the pharmacy going to be able to meet the set goals?set goals?Is anything missing?Is anything missing?What changes can be made in the business What changes can be made in the business plan to improve the return on investment? plan to improve the return on investment?

$3,011.00($11,362.00)Profit

Improving ROI: Potential Improving ROI: Potential Modifications to the Business PlanModifications to the Business Plan

Depreciate cost of equipment over useful Depreciate cost of equipment over useful life of equipment vs recognize all costs in life of equipment vs recognize all costs in year oneyear one–– Estimate 5Estimate 5--year depreciation @ $2,500 per year year depreciation @ $2,500 per year

$711.00($1,862.00)Profit


Group purchase of BMD equipmentGroup purchase of BMD equipment–– Example: 4 pharmaciesExample: 4 pharmacies

»» Each pharmacy uses machine 1 week monthlyEach pharmacy uses machine 1 week monthly

Develop written agreement regarding:Develop written agreement regarding:–– Machine schedulingMachine scheduling–– OwnershipOwnership–– Maintenance responsibilities, etc. Maintenance responsibilities, etc.



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Do more screeningsDo more screenings–– OffOff--site Venuessite Venues

»» Health clubsHealth clubs»» Senior centersSenior centers»» Physician officesPhysician offices»» Local hospitalsLocal hospitals»» Community centersCommunity centers»» Places of worshipPlaces of worship»» SchoolsSchools»» EmployersEmployers»» Health fairsHealth fairs

–– Engage Pharmaceutical RepresentativesEngage Pharmaceutical Representatives»» Detail physicians and to partner with youDetail physicians and to partner with you»» Providing financial assistance for screenings in the communityProviding financial assistance for screenings in the community

–– Increase number of hours devoted to screenings or screenings perIncrease number of hours devoted to screenings or screenings per hourhour


Engage pharmacy support personnelEngage pharmacy support personnel–– Pharmacy technician performs the BMD test Pharmacy technician performs the BMD test

and pharmacist consults with patient on test and pharmacist consults with patient on test results results

–– Offsets additional cost of technician by Offsets additional cost of technician by increasing number of screenings and decreasing increasing number of screenings and decreasing pharmacist time involved in conducting the testpharmacist time involved in conducting the test

Return on Investment Analysis Return on Investment Analysis -- RevisedRevised

1,660.001,510.00BMD machine

$11,595.00$8,110.00Total Expenses1,500.001,000.00Advertising/promotion

0.00400.00Pharmacist training 200.00350.00Other supplies

75.0050.00Documentation supplies8,160.004,800.00Additional staffing

Year TwoYear OneExpenses



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Return on Investment AnalysisReturn on Investment Analysis-- RevisedRevised

Direct Revenue2,400.00 1,200.00Prescription Revenue

$6,117.00$2,522.00Profit17,712.0010,632.00Total Revenue

912.00432.005% of screening customers will buy calcium supplements

Indirect Revenue14,400.009,000.00Screening Fees

Year TwoYear One

Make your Make your assumptions reasonable assumptions reasonable and attainableand attainable--

THEN BE THEN BE AGGRESSIVE AND AGGRESSIVE AND KNOCK THE BALL KNOCK THE BALL OUT OF THE PARKOUT OF THE PARK

Osteoporosis Care Certificate Program Osteoporosis Care Certificate Program Pharmacy Based Bone Density TestingPharmacy Based Bone Density Testing

Planning ConsiderationsPlanning ConsiderationsReimbursement IssuesReimbursement IssuesBusiness Plan DevelopmentBusiness Plan DevelopmentApplication Exercise #5 Application Exercise #5



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√√ Check Point Check Point How Well Are You Able to:How Well Are You Able to:

List three reasons why pharmacists should List three reasons why pharmacists should consider offering Bone Mass Density (BMD) consider offering Bone Mass Density (BMD) testingtestingDescribe the statement of medical necessity and its Describe the statement of medical necessity and its role in billing for osteoporosis care services role in billing for osteoporosis care services Define the billing codes necessary to complete a Define the billing codes necessary to complete a CMS 1500 formCMS 1500 formDevelop a business plan for an osteoporosis Develop a business plan for an osteoporosis screening and management services screening and management services Describe the basic procedure for operating an Describe the basic procedure for operating an ultrasound BMD testing device ultrasound BMD testing device Discuss the necessity for Quality Control when Discuss the necessity for Quality Control when operating BMD testing devicesoperating BMD testing devices

Take Time to Review if Take Time to Review if NecessaryNecessary

List three reasons why pharmacists should consider List three reasons why pharmacists should consider offering Bone Mineral Density (BMD) testing offering Bone Mineral Density (BMD) testing [Planning [Planning Considerations]Considerations]Describe the statement of medical necessity and its role in Describe the statement of medical necessity and its role in billing for osteoporosis care services billing for osteoporosis care services [Reimbursement [Reimbursement Issues]Issues]Define the billing codes necessary to complete a CMS Define the billing codes necessary to complete a CMS 1500 form 1500 form [Reimbursement Issues][Reimbursement Issues]Develop a business plan for an osteoporosis screening and Develop a business plan for an osteoporosis screening and management services management services [Business Plan Development][Business Plan Development]Describe the basic procedure for operating an ultrasound Describe the basic procedure for operating an ultrasound BMD testing device BMD testing device [Planning Considerations][Planning Considerations]Discuss the necessity for Quality Control when operating Discuss the necessity for Quality Control when operating BMD testing devices BMD testing devices [Planning Considerations][Planning Considerations]

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Documents

Pharmacy-Based Bone Density Testing · Pharmacy-Based Bone Density Testing Question 1 Which of the following is a feasible site for BMD screening services? A. Physician office B