PSTAC
Pharmacist Services
Technical Advisory Coalition
www.pstac.org
Agenda
• Who is PSTAC?
• What does PSTAC do?
• What has it accomplished?
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Coding for Services
Taxonomy Codes
Companion Guide
Website
• What’s next?
www.pstac.org
Glossary of Terms
• ANSI: American National Standards Institute - Accredits the
Standards Development Organizations (SDOs)
• ASC X12N: Accredited Standards Committee X12N is the
insurance subcommittee of the parent SDO
• CMS: Centers for Medicare and Medicaid Services
• CPT: Current Procedural Terminology – codes defined by the
American Medical Association (AMA) which are used to bill for
health care services
• DSMO: Designated Standard Maintenance Organization –
created by HIPAA, organizations that maintain standards for
electronic transactions established by the Secretary of HHS.
www.pstac.org
Glossary of Terms
• EDI: Electronic Data Interchange
• HCPAC: Health Care Professional Advisory Committee – a
subcommittee of AMA’s CPT Editorial Panel that represents
non-physician providers
• HCPCS: Healthcare Common Procedure Coding System standard code set for reporting supplies, orthotic and
prosthetic devices, and durable medical equipment
• HHS: Department of Health and Human Services
• HIPAA: Health Insurance Portability and Accountability Act
of 1996
www.pstac.org
Glossary of Terms
• NCPDP: National Council for Prescription Drug Programs
• NPI: National Provider Identifier
• NUCC: National Uniform Claim Committee – develops
standardized data set to transmit claim information to
third party payers (1500 Claim Form)
• POS: Place of Service – code to identify location patient
service provided
• SDO: Standards Development Organization
www.pstac.org
PSTAC Mission
Improve the coding infrastructure
necessary to support billing for
pharmacists’ professional services.
www.pstac.org
PSTAC Member Organizations
www.pstac.org
PSTAC Operations
• Steering Committee
– Coalition member staff liaisons, plus
– 2 appointments per member organization
– Convenes three times annually
• Work Groups
– Maintenance Work Group
• maintains Pharmacy Companion Guide
• maintains PSTAC website
– Coding Work Group
• evaluates and responds to CPT coding needs
www.pstac.org
Change Request Process
• Code (data element) Request
– Add
– Delete
– Modify
• Companion Guide (transaction segment)
Request
– Add
– Delete
– Modify
www.pstac.org
Historical Perspective
• HIPAA standards for the transmission of
electronic health care claims transaction
formats and code sets
– Administrative simplification provisions of HIPAA
published by HHS as the TCS Rules on August 17,
2002
– Retail Pharmacy Prescription Drug claims
• Use NCPDP - National Drug Codes (NDC)
– Professional Service claims
• Use X12N 837 (CPT or HCPCS codes)
www.pstac.org
Electronic Data Interchange (EDI)
• Refers to “the electronic transfer of information
(data) in a standard format between trading
partners.”
• When compared with paper submissions, EDI
– reduces the time and costs associated with receiving,
processing, and storing documents
– eliminates inefficiencies and streamlines processing
tasks, resulting in less administrative burden, lower
operating costs, and improved overall data quality
www.pstac.org
NCPDP’s Role in Pharmacy
National Council for Prescription Drug
Programs
• Creates and promotes standards for the transfer
of data to and from the pharmacy services sector
– primarily prescription drug claims and e-prescribing
standards
• ANSI accredited
• One of several SDOs involved in health care
information technology & standardization
www.pstac.org
ASC X12N’s Role in Pharmacy
Insurance Subcommittee of the Accredited
Standards Committee X12
• Creates and promotes standards for the transfer of
data to and from the pharmacy services sector
– primarily professional service claims and DME
• ANSI accredited
• One of several SDOs involved in health care
information technology & standardization
www.pstac.org
Impact of EDI Provisions of
HIPAA on Pharmacy
• Claims required to be X12N 837 compliant:
– Professional Pharmacist Services
– Durable Medical Equipment
– Prosthetics and Orthotics
• Provides Pharmacy access to CPT code
development process
• Eliminates “local” codes
www.pstac.org
PSTAC Objectives
 Create the vision for an infrastructure to support
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billing and payment for pharmacists’ professional
services
Integrate pharmacy into national organizations,
systems & coding nomenclature to support
documentation & claims transactions used by other
health care providers, health care facilities and
health plans.
Provide national leadership to position & secure
pharmacy’s place in the X12 environment.
www.pstac.org
PSTAC Milestones
January 2002: The first Pharmacy Companion Guide
was released by X12 Pharmacy Advisory Panel
April 2002: X12 Pharmacy Advisory Panel changed
name to Pharmacist Services Technical Advisory
Coalition (PSTAC)
June 2003: PSTAC received AMA recognition in CPT
process as an official member of the AMA Health Care
Professionals Advisory Committee (HCPAC)
September 2003: Addendum to the Pharmacy
Companion Guide released
November 2003: AMA Board of Trustees approved
PSTAC nominee to HCPAC
www.pstac.org
PSTAC Milestones
February 2005: Received approval from AMA for pharmacist
MTM Service codes as Category III CPT codes
June 2005: NUCC approved new place of service (POS)
code for Pharmacy
August 2005: NUCC approved new Health Care Provider
Taxonomy Code for Pharmacists
November 2005: Pharmacy Companion Guide, 2nd Ed.
released
December 2005: NUCC approved new Health Care Provider
Taxonomy Code for Pharmacies
www.pstac.org
PSTAC Milestones
January 2006: MTM Service Codes implemented as
Category III codes
July 2006: Health Care Provider Taxonomy Code List
updated for Pharmacy Service providers & suppliers
August/September 2006: PSTAC surveyed payers &
providers on the use of MTM Service Codes in the
marketplace
November 2006: PSTAC submitted a proposal to AMA’s CPT
Panel for MTM Code change from Category III to Category I
December 2006: PSTAC released report on MTM Provider &
Payer survey
www.pstac.org
PSTAC Milestones
October 2007: PSTAC received approval from the AMA to
reclassify pharmacist MTM Service codes from Category
III to Category I
- this changed the status of pharmacist MTM codes from
“emerging technology” to recognized standard of care
and improved recognition by and acceptability to
payers
www.pstac.org
New Pharmacist-only
CPT Codes
• Three (3) ‘pharmacist only’ CPT professional service
codes to bill third-party payers for MTM Services
delivered face-to-face between a pharmacist and a
patient including, but not restricted to Medicare Part D:
– 99605 is to be used for a first-encounter service (up
to 15 minutes)
– 99606 is to be used for a follow-up encounter with an
established patient (up to 15 minutes)
– 99607 may be used with either 99605 or 99606 to bill
additional 15-minute increments.
• Initially approved as Category 3 (“emerging technology”
or “tracking”) codes. Reclassified as Category 1 and will
become eligible for use January 1, 2008.
www.pstac.org
What is MTM?
• Medication Therapy Management services (MTM)
describe face-to-face patient assessment and
intervention as appropriate, by a pharmacist
• MTM includes the following documented elements:
– review of the pertinent patient history
– medication profile (prescription and non-prescription)
– recommendations for improving health outcomes and
treatment compliance.
• These codes are not to be used to describe the provision
of product-specific information at the point of dispensing
or any other routine dispensing-related activities.
www.pstac.org
Clinical Vignettes
• Intended to serve as a powerful tool for
providers of services
• Do not infer any judgment of importance of the
service described
• Provide applicability of the CPT code
• One vignette per code
• Each vignette consists of 3 components:
– Pre-service activities
– Intra-service activities
– Post-service activities
www.pstac.org
Pre-Service Activities
• Obtaining patient intake information
• Gathering or preparing materials that will be
used during the patient encounter
• Coordination of other support staff.
www.pstac.org
Intra-Service Activities
• Assessment of the patient
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obtain a patient medical and medication history
determine appropriateness of medication therapy
perform a review of relevant systems
evaluate pertinent lab data
assess potential or existing drug interactions
establish and/or obtain additional information, as needed
develop a care plan including recommendations for optimizing
medication therapy
• Pharmacist interventions
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provide education, training and resources
administer medication
formulate a treatment and/or follow-up plan
provide recommendations for disease prevention
evaluate patient knowledge of medication and willingness to
implement recommendations
www.pstac.org
Post-Service Activities
• Documentation of the patient encounter
• Non face-to-face interventions and
recommendations
• Referrals
• Communication with other healthcare
professionals
• administrative functions (including patient and
family communications) relative to the patient’s
care
• Scheduling follow-up appointment(s) as
appropriate.
www.pstac.org
Sample Clinical Vignettes
• 99605:
– A 66 year-old female with pre-existing osteoporosis has been
diagnosed with type 2 diabetes and hyperlipidemia. Initial
medication therapy assessment and intervention is performed.
• 99606:
– A 66 year-old female with osteoporosis, type 2 diabetes, and
hyperlipidemia is receiving follow-up reassessment after
receiving a prior medication therapy management service.
• 99607:
– Intra Service Only
– The services continued for an additional 15 minutes with the
same patient.
www.pstac.org
Example
Primary Code
Incremental Code
Initial
Service
Subsequent
Service
99605
99606
99607
Example: 45-minute encounter with a new patient
Primary Code (99605)
+ Incremental Code (99607) x 2
www.pstac.org
MTM Services Provider Survey
• Distributed to the profession through PSTAC member
organizations and to the U.S. Department of Veterans
Affairs
• 240 practice sites responded
– all 50 states plus D.C. and Puerto Rico
– 86% were ambulatory care practice sites
• Results:
– 858,405 face-to-face MTM service encounters reported over a twoyear period, with additional 1.8 million reported by the VA.
– Most MTM patients had been referred by their physician
– 26.5% of providers reported submitting MTM claims using the
MTM Service codes
www.pstac.org
MTM Services Payer Survey
• 8 payers responded to survey
– active in all 50 states, D.C. and Puerto Rico
• Results:
– 88% of paid claims:
• Comprehensive medication reviews
• Identifying or resolving drug therapy problems
– 7 of 8 payers indicated that face-to-face encounters
represented >75% of claims
– Community pharmacies and clinics were the most
common location for delivery of MTM services
– 6 of 8 payers used X12N 837 claim format
• remaining 2 payers used a proprietary format/system
www.pstac.org
Coding for Services
• Place of Service (POS) codes
• CPT codes
• Evaluation & Management (E&M) codes
• MTM Service codes
• Taxonomy Codes
www.pstac.org
Place of Service (POS) Codes
• Used on medical claims to identify physical
location where service was performed
• PSTAC secured a POS code to be used by
pharmacists billing for services in a pharmacy
setting
– POS Code 01, "Pharmacy"
– Effective October 1, 2005
• This new code supplements other POS codes
typically used by pharmacists such as
– Code 11, "Office“
– Code 99, "Other Place of Service"
www.pstac.org
Evaluation & Management
(E&M) CPT Codes
• Previously utilized by some pharmacists to
submit claims to payers
• Have important shortcomings:
– very non-specific so they fail to accurately track
and report pharmacists’ MTM services
– often result in undervaluation of pharmacists’
services
www.pstac.org
Additional Information on
MTM Service Codes
• PSTAC website:
http://www.pstac.org/services/mtms-codes.html
– code model
– rationale
– clinical vignette for each code
• AMA website:
http://www.ama-assn.org/ama/pub/category/3885.html
www.pstac.org
Health Care Provider
Taxonomy Codes
• Codes identify:
– Provider type
– Classification
– Area of specialization
• Applied to:
– Pharmacy Service Providers
– Pharmacy Suppliers
• Complete Taxonomy Code List can be found at:
www.wpc-edi.com/codes/taxonomy
www.pstac.org
Pharmacy Service Providers
Taxonomy Codes
• Pharmacist - 183500000X
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General Practice - 1835G0000X
Geriatric - 1835G0303X
Nuclear - 1835N0905X
Nutrition Support - 1835N1003X
Oncology - 1835X0200X
Pharmacotherapy - 1835P1200X
– Psychiatric - 1835P1300X
• Pharmacy Technician - 183700000X
www.pstac.org
Pharmacy Suppliers
Taxonomy Codes
• Pharmacy - 333600000X
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Clinic Pharmacy - 3336C0002X
Community/Retail Pharmacy - 3336C0003X
Compounding Pharmacy - 3336C0004X
Home Infusion Therapy Pharmacy - 3336H0001X
Institutional Pharmacy - 3336I0012X
Long Term Care Pharmacy - 3336L0003X
Mail Order Pharmacy - 3336M0002X
Managed Care Organization Pharmacy - 3336M0003X
Nuclear Pharmacy - 3336N0007X
Specialty Pharmacy - 3336S0011X
www.pstac.org
ASC X12N 837 Health Care Claim:
Pharmacy Professional
Services Companion Guide
• Primary purpose is to help payers and vendors
program their systems to send & receive
HIPAA-compliant transactions for pharmacy
service billing.
www.pstac.org
Pharmacy Companion Guide
• Intended to expedite implementation of
pharmacy professional service claims
• Needs to be implemented uniformly by all users
within the health care industry to facilitate a
smooth transition into the EDI environment
www.pstac.org
Pharmacy Companion Guide
• Does NOT:
– Add any new data elements, segments or functions to
the parent 837 Professional Implementation Guide
– Remove any required information
– Modify the definition, condition, or use of a data
element or segment
– Utilize any code or data values that are not valid
– Change the meaning or intent of the parent IG
– Specify hardware and software requirements
– Define the electronic media communication link
between trading partners
www.pstac.org
Pharmacy Companion Guide
New Features (2nd Ed.)
• The entire EDI transaction set listing from
the parent Implementation Guide with
transactions that are NOT used shadowed
in gray
• One transaction set listing for single-payer
implementation AND one for coordination
of benefits
• Expanded illustrative cases of service
claims
www.pstac.org
How to Order
Pharmacy Professional Service
Companion Guide
• Washington Publishing Company, the official publisher of
X12 IGs
• www.wpc-edi.com
• http://www.wpc-edi.com/products/publications/pstac
www.pstac.org
PSTAC Website
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Meeting schedule
FAQ section
Master inventory of codes
Press releases
Request Form for new data elements and
data segments
• Committee information for members
• www.pstac.org
www.pstac.org
What’s Next for PSTAC?
 Stimulate a nationwide educational initiative to educate
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pharmacists on billing codes and proper coding techniques
Stimulate payer awareness of coding for pharmacy services
Continue identification and development of new codes and
pharmacist support tools
Continue to promote the pharmacist’s role as provider of
services to help improve therapeutic outcomes
Continue to update the Pharmacy Companion Guide as
needed to remain current
Work with HCPAC Relative Value Update Committee (RUC)
to assign research-based relative values for MTM Service
codes
www.pstac.org
Joining PSTAC
• PSTAC is open to pharmacy providerbased organizations
• If your organization wishes to join, email a
request to: [email protected]
www.pstac.org
Questions?
www.pstac.org
Thank You!
www.pstac.org