Mtm Billing Form Washington State Pharmacy Association (Page 2 of 2) in pdf

OUTCOMES ENCOUNTER PROGRAM DOCUMENTATION FORM

INSTRUCTIONS FOR USE

This form is used to document services provided in the Outcomes Encounter Program. Claims are collected via the Outcomes website at:

PROVIDER LOGON

From the home page, select the “Log in” tab from the top of any page and enter the following information:

Pharmacist ID Number: Input the 2 letter state abbreviation plus the license number of the PHARMACIST providing the Encounter service [i.e.IA12345].

NCPDP/NABP Number: Input the NABP or NCPDP number for the PHARMACY at which the Encounter service was performed.

Password: Input the password for the PHARMACIST providing the Encounter service.

PATIENT INFORMATION

Patient information is accessed via the Patient ID field when submitting a claim through the website. In most cases, the ID number is found on the patient’s benefit

card (this number is not always the cardholder’s social security number) and, in most cases, is followed by the patient’s two-digit person code [i.e. 12345678901].

After entering the ID number, select Get Patient Info. This will fill in patient-specific information.

PRESCRIPTION INFORMATION

Final Rx: The information in this area reflects the primary drug involved in the Encounter being billed. If the Encounter involves a change in therapy from

one agent to another, the dispensed prescription information is entered here.

Initial Rx: If the Encounter involves a change in therapy from one agent to another, the initial prescription information is entered here. Fields to complete

in this area are: Date dispensed, Rx number [when applicable], New vs. Refill, Metric quantity, Days supply, NDC code, and Prescriber DEA number.

Frequency of Therapy: Indicate the anticipated frequency of the Final Rx.

• Acute [only a single course of therapy anticipated to treat condition (i.e. acyclovir to treat chicken pox)]

• Intermittent [occasional courses of therapy anticipated to treat condition (i.e. acyclovir to treat recurrent herpes outbreaks)]

• Chronic [ongoing therapy anticipated to treat condition (i.e. acyclovir used for herpes suppression)]

ENCOUNTER DOCUMENTATION

Indication for Service [Reason]: Indicate which reason code best describes the Encounter performed.

• Complex Drug Therapy

• Cost Efficacy Management

• New or Changed Prescription Therapy

• OTC Therapy

• Drug Therapy Problem Detected [select from 10 subcategories]

• Other [use if the reason for the Encounter does not fit any of the subheadings; must thoroughly explain Encounter in notes]

Professional Service [Action]: Select an action code that corresponds within the same color path as the reason.

• Comprehensive Medication Review (CMR)

• Prescriber Consultation

• Patient Education and Monitoring [both Patient Education and Monitoring must occur for service to be covered]

• Patient Consultation [corresponds with Cost Efficacy Management patient refusals and compliance-related Encounters]

Outcome of Service [Result]: Select a result code that corresponds within the same color path as the selected reason and action codes.

• CMR with or without Encounter

• Initiation of Cost Effective Drug

• Therapeutic Success [Condition Resolved or Condition Stable]

• Therapeutic Failure [Condition Unresolved or Condition Worsened]

• Drug Therapy Problem Resolved [select from 8 subcategories]

• Patient Refusal [use if the patient declines services or if the patient cannot be contacted for services]

• Prescriber Refusal [use if the prescriber declines a recommendation to alter drug therapy]

• Other: [use if the reason for the Encounter doesn't fit any of the subheadings; must explain Encounter fully in the notes]

When documenting a “Result” code under Drug Therapy Problem Resolved, the “Result” code must correspond with the bolded subcategory

indicated under Drug Therapy Problem Detected “Reason” code.

For example: If the Drug Therapy Problem Detected is under Efficacy (i.e. Suboptimal Drug Selection), the choices for Drug Therapy Problem

Resolved are also listed under Efficacy (i.e. Changed Drug or Increased Dose/Duration)

Estimated Cost Avoidance: Indicate the level of the Estimated Cost Avoidance, in your professional judgment, which has occurred due to the encounter

performed. The dollar value will be assigned by Outcomes. The Encounter Claims will be audited to assure reasonable and foreseeable cost avoidance

measurements [choose only 1].

• Level 1 Improved Quality of Care [Encounter improved health care quality with no direct avoided costs calculated]

• Level 2 Drug Product Costs [Encounter resulted in reduced or avoided drug product costs]

• Level 3 Additional Physician Visit [Encounter resulted in an avoided physician visit]

• Level 4 Additional Prescription Order [Encounter resulted in an avoided prescription order (includes physician visit costs)]

• Level 5 Emergency Room Visit [Encounter resulted in an avoided emergency room visit]

• Level 6 Hospital Admission [Encounter resulted in an avoided hospitalization]

• Level 7 Life Threatening [Encounter resulted in an avoided life threatening event (includes hospitalization costs)]

• Prescriber/Patient Refusal [Encounter resulted in no direct avoided costs due to patient or prescriber refusal]

• See Previous Claim # [used when 2 or more Encounter Claims are linked to a single Estimated Cost Avoidance]

Encounter Notes And Estimated Cost Avoidance Rationale: Provide a thorough description of what occurred during the Encounter and the rationale

behind the Estimated Cost Avoidance level chosen.

Mtm Billing Form Washington State Pharmacy Association Page 2

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