ASHP InterSections ASHP InterSections

July 22, 2015

Pharmacists Integrate into Geriatric Emergency Department

EDITOR’S NOTE: The American College of Emergency Physicians (ACEP) recently approved a policy supporting clinical pharmacy services in emergency departments (EDs). ACEP’s policy notes that pharmacists serve a “critical role in ensuring efficient, safe, and effective medication use,” and calls on health systems to support dedicated roles for pharmacists in the ED that involve pharmacists as active participants in patient care decisions, including resuscitations, transitions of care, and medication reconciliation. Members of the ASHP Section of Clinical Specialists and Scientists’ advisory group on emergency medicine worked with the ACEP’s New York affiliate to introduce and champion a resolution that led to the formal policy statement. The below story originally appeared in ASHP InterSections on Jan. 19, 2015.

ACEP recently endorsed the valuable role of pharmacists in the ED, including an active role in  resuscitations, transitions of care, and medication reconciliation.

ACEP recently endorsed the valuable role of pharmacists in the ED, including an active role in resuscitations, transitions of care, and medication reconciliation.


WHEN UPSTATE UNIVERSITY HOSPITAL in Syracuse, New York, began looking at adding a geriatric emergency department (ED) to Community Campus, the pharmacy department did not have to ask about participating, said director Beth Szymaniak.

“We were invited to be on the committee, and we were automatically assumed . . . to be a part of it,” Szymaniak said of the eight-bed geriatric ED, which opened in July 2013. “We just had to figure out how many FTEs [full-time equivalents] we wanted.”

The number of pharmacist FTEs in the geriatric ED is now 2, which was the pharmacy department’s original request, said the long-time director.

Pharmacist services should be an ancillary service of all geriatric EDs, according to a set of guidelines developed by two nonpharmacy organizations.

Approved in October 2012 by the American College of Emergency Physicians Geriatric Section and the Academy of Geriatric Emergency Medicine, the document “Geriatric Emergency Department Guidelines” supports dual goals for an ED specializing in the care of people 65 years of age or older:

•    Recognize the patients who will benefit from inpatient care.
•    Efficiently provide outpatient care to those who do not require inpatient resources.

The guidelines recommend completion of a medication list for all patients 65 years of age or older arriving to the ED.

The guidelines do not recommend a specific professional for completing the medication list. But they do recommend a multidisciplinary approach to managing patients who are taking more than five medications, using any “high-risk” medication, or experiencing signs or symptoms of an adverse drug event.

Nikolas Onufrak, one of the two pharmacists in Upstate University Hospital at Community Campus’s geriatric ED, said the multidisciplinary team strives to prevent initial hospitalizations and also repeat visits due to lack of comprehensive care.

Kelly_BrahamSo far, said pharmacist Kelly R. Braham, the admission rate for patients from the geriatric ED, which operates 8 a.m. to 10 p.m. daily, has decreased to 35% from an initial 42%.

Braham and Onufrak said their primary responsibility as geriatric emergency medicine pharmacists is to analyze patients’ medication regimens.

However, getting to the point of being able to analyze the regimens, Onufrak noted, requires “a little detective work.”

That means a lot of phone calls to pharmacies and physician offices and conversations with patients and family members, he said.

“We do the best we can to figure out what they actually are taking and reconcile that with the reason why they’re presenting to us,” he said. Then attention turns to assessing the appropriateness of all the medication regimens and determining whether any relate to the ED visit.

Braham said she and Onufrak pay particular attention to the overall anticholinergic burden of patients’ medications and use two tools—the STOPP (Screening Tool of Older People’s Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria—to identify potentially inappropriate prescribing in older people.

The two pharmacists also check for drug interactions before recommending interventions, she said.

And the pharmacists educate the patient as much as possible about every medication on the list and the drug’s purpose.

For a substantial percentage of the patients, said Onufrak, “there are significant [medication-related] interventions to be made at the point of care when they come into the ED.”

For a substantial percentage of the patients, there are significant [medication-related] interventions to be made at the point of care when they come into the ED.

Braham recounted one such case from just the previous week.

“He came in and he was taking both apixaban and rivaroxaban,” she said of the patient, who did not speak English.

“They were prescribed by two different providers; neither was his primary care doctor. However, he had been on this regimen since May.”

A computed tomography scan of the man’s head showed no sign of bleeding despite his taking the two anticoagulants for six months and recently falling down, Braham said.

“How he got by for that long I don’t know, but that’s something that we definitely rectified,” she said.

More common, Braham said, is the pharmacist’s recommendation to change a patient’s hypertension therapy to avoid a medication that causes orthostatic hypotension, which is a fall risk.

Onufrak said he and Braham typically see 20–30 patients over the course of a 10-hour workday. Not all of these patients are in the geriatric ED, however.

Nikolas_OnufrakAs time permits, the two pharmacists also see patients in the transitional care unit and general ED. Whether geriatric EDs lower costs remains uncertain, however.

An observational study at a community hospital in Ann Arbor, Michigan, found that after its geriatric ED opened in October 2010, patients 65 years of age or older had a lower risk of hospital admission than when that population was seen in the general ED.

But there were no differences in the risks of a repeat ED visit within 30 and 180 days. Neither was there a change in the average length of stay for those patients admitted to the hospital. The researchers reported that the pharmacists evaluated only selected patients in the geriatric ED.

A three-hospital study of geriatric EDs in Illinois, New Jersey, and New York is underway, funded with $12.7 million from the Centers for Medicare and Medicaid Services’ Innovation Center.

Known as Geriatric Emergency Department Innovations in care through Workforce, Informatics, and Structural Enhancements (or GEDI WISE), the study is projected to yield $40.1 million in cost savings.

These savings, the study investigators stated, will come from reductions in hospital admissions, readmissions within 30 days, ED visits, repeat ED visits, and days in the intensive care unit.

“Geriatric Emergency Department Guidelines” is available from


 –By Cheryl A. Thompson, reprinted with permission from AJHP (Jan. 15, 2015; volume 72, pages 92, 94)

January 19, 2015

Pharmacists Praise New Medicare Billing Opportunities

Filed under: ASHP News,Clinical,Feature Stories,Provider Status,Uncategorized — Tags: , , , , — jmilford @ 5:12 pm

RECENT UPDATES TO THE INCIDENT-TO BILLING REQUIREMENTS from the Centers for Medicare and Medicaid Services (CMS) have created new opportunities for medical practices to be reimbursed for pharmacists’ patient care services.

“Change is happening,” said Sandra Leal, medical director of pharmacy at El Rio Community Health Center in Tucson, Arizona. “What’s exciting is that there is more consideration from CMS to have pharmacists participate in teams and to . . . bill with the physician,” she said.

Sandra_LealLeal said the new billing opportunities arise from clarifications from CMS on work done by nonphysician healthcare providers and language in the agency’s 2015 update to the physician fee schedule.

The fee schedule, released this past November, allows physicians to bill Medicare for unsupervised after-hours services provided by nonphysicians under Medicare’s chronic care management (CCM) and transitional care management (TCM) programs. The person who provides these services incident to a physician’s care need not be a direct employee of the medical practice, according to CMS.

TCM and CCM services involve face-to-face care and comprehensive follow-up, including medication therapy management, within a specific time frame.

CMS began reimbursing medical practices for TCM services in 2013, and Leal said her clinic participates in this program. She said in November that no decision had yet been made about providing CCM services.

“Our compliance officer is actually reviewing the language right now to see if it makes sense for us to be able to  participate,” she said.

The 2015 fee schedule doesn’t state outright that physicians can bill for pharmacists’ TCM and CCM services provided incident to the physician’s care.

Instead, the fee schedule refers to physicians’ clinical staff and the time spent by those nonphysician healthcare professionals in providing TCM and CCM services.

But a March 2014 letter from CMS Administrator Marilyn Tavenner affirmed that pharmacists are among the nonphysician healthcare providers for whom incident-to billing is permissible [see June 15, 2014, AJHP News].

CMS regulations for 2014 also specified that nonphysician healthcare professionals must meet state requirements for licensure and work within their state’s scope of practice regulations in order to participate in incident-to billing.

Betsy Bryant Shilliday, associate professor of medicine at the University of North Carolina (UNC) School of Medicine in Chapel Hill and assistant medical director for the UNC internal medicine clinic, said the reference to state law has greatly benefited her clinic.

That’s because North Carolina has established the clinical pharmacist practitioner (CPP) credential, an advanced practice designation conferred by the state’s pharmacy and medical boards.

Under North Carolina state law, CPPs are “approved to provide drug therapy management, including controlled substances, under the direction of, or under the supervision of a licensed physician.”

A March 2014 letter from CMS Administrator Marilyn Tavenner affirmed that pharmacists are among the nonphysician healthcare providers for whom incident-to billing is permissible.

A March 2014 letter from CMS Administrator Marilyn Tavenner affirmed that pharmacists are among the nonphysician healthcare providers for whom incident-to billing is permissible.

Shilliday said her regional Medicare carrier—or Medicare administrative contractor (MAC), as the entities are officially designated—recently agreed that CPP-certified pharmacists qualify for incident-to billing using higher-level Current Procedural Terminology (CPT) codes.

Specifically, she said, physicians can bill using CPT codes 99211–99214 for pharmacists’ incident-to services.

“This was my Christmas present. I’m like a kid in a candy store now,” Shilliday said in November.

Shilliday recalled that about a decade ago, her Medicare carrier allowed higher-level incident-to billing by pharmacists. But that changed when a different carrier assumed responsibility for the region.

At that time, she said, pharmacists’ services were restricted to the minimal evaluation and management CPT code, 99211, regardless of the time spent with the patient and the complexity of the patient’s condition or the medical decision-making involved in the visit.

“We’d been going along that path, providing very complex care but getting reimbursed very little,” Shilliday said.

“So it’s been very hard for us to justify to practices to hire more pharmacists, because we’re expensive. And our reimbursement rates are very low, especially if we’re in a high Medicare population clinic.”

She said the new ruling from the MAC will provide a better return on the clinic’s investment in pharmacists’ services. Her compliance office is also attempting to justify billing at the highest level, 99215.

“However, we’re happy to bill up to a 99214. It’s huge, it’s over three times what we are able to bill for a [99211] visit,” she said.

Shilliday said that although the CPP credentialing process for North Carolina pharmacists helped sway the Medicare carrier’s approval of higher-level billing, pharmacists in states without a similar advanced practice designation might also be able to use higher-paying CPT codes.

We’re happy to bill up to a 99214. It’s huge, it’s over three times what we are able to bill for a [99211] visit.

“I would very much explore it in another state as well and see how they interpret it. Because each Medicare carrier can interpret it differently,” she said.

Shilliday said she and her colleagues are exploring whether the clinic meets CMS’s requirements to bill for TCM and CCM services. She said potential problems with billing for these services include the need to obtain a written agreement from patients to receive the care.

Medicare coinsurance and deductibles apply to TCM and CCM services, which could pose an obstacle to patients’ acceptance of the services.

Shilliday and Leal welcomed the new opportunities for reimbursement of pharmacists’ patient care services. But they emphasized that incident-to billing is not a substitute for the recognition of pharmacists as healthcare providers under the Social Security Act.

Shilliday noted that her MAC’s previous refusal to allow higher-level billing for pharmacists’ incident-to services was based on the fact that CMS didn’t list pharmacists as recognized providers.

Leal explained that incident-to billing “only covers what the provider specifically asks for you to help with.”

If a physician refers a patient to a pharmacist for diabetes management, only those services are billable as incident to the physician’s service. This applies even if the pharmacist discovers during the encounter that the patient has uncontrolled hypertension or other problems and addresses those.

“You will [treat them], because that’s our clinical obligation. But for reimbursement purposes, you’re only able to do what the [physician] asks you to do,” Leal said.

Thus, to allow pharmacists broader opportunities to use their skills and be reimbursed for their work, “it’s very critical to get provider status,” Leal said.

 –By Kate Traynor, reprinted with permission from AJHP (Jan. 15, 2015; volume 72, pages 91-92)

April 3, 2014

New ASHP eReports Focus on Practice Challenges

Filed under: Ambulatory Care,ASHP News,Clinical,Current Issue,InfoCentral — Kathy Biesecker @ 12:25 pm

ASHP RECENTLY LAUNCHED a new product line in its eBookstore called “ASHP eReports.” Similar to Amazon Kindle Singles, the eBook publications cost $9.95 each and focus on specific practice topics. Check out the current offerings at

March 13, 2014

A Bold New Look, Feel for the ASHP Summer Meetings


ASHP's Summer Meeting has evolved into three boutique meetings that are held in the same venue. This year, they are in Las Vegas, May 31-June 4.

ASHP’s Summer Meeting has evolved into three boutique meetings that will be held in the same venue. This year, they will take place in Las Vegas, May 31-June 4.

The 2014 ASHP SUMMER MEETINGS in Las Vegas will look very different from their predecessors. Instead of a single large meeting, participants can choose from three concurrent and unique “boutique” conferences, each of which follows a specialized subject track. Welcome to the new ASHP Summer Meetings (note the intentional plural)!

“We looked at what makes some of our smaller meetings so successful year after year. What stood out clearly [in meetings like the Conference for Leaders in Health-System Pharmacy and the National Pharmacy Preceptors Conference] were the like-mindedness and shared interests of the people who attended,” said Michelle C. Abalos, Pharm.D., ASHP director of educational programs.

“Attendees had a common purpose and common goals, and many had similar professional responsibilities. Because the topics were very focused, participants felt the meeting was just for them.”

By applying the same structure to the new Summer Meetings, ASHP is focused on creating a heightened sense of purpose and inclusiveness by offering participants the opportunity to delve deeply into topics that are most relevant to their professional lives.

The Next Generation of Learning

Three meetings will share the spotlight this year: Informatics Institute; Pharmacy, Practice, & Policy; and Medication Safety Collaborative.

“Attendees want meaningful connections and to interact with peers who have common goals.”

The Medication Safety Collaborative set the stage for this new boutique meeting model with its roll-out as a pilot program at the 2013 Summer Meeting. The four-day event included educational sessions, networking, and other activities led by some of the foremost medication safety experts in the country.

The response was overwhelmingly positive. When asked what they liked about their experiences, attendees mentioned the chance to interact with like-minded peers over several days, a sense of community and unified purpose, a dedicated physical space and dedicated ASHP staff, a supportive networking atmosphere, the interprofessional nature of the event, and education programs that ‘spoke to them.’

This year’s Collaborative once again features distinguished experts in the field who will challenge participants to apply new knowledge and skills and build competency in areas such as integrating human and environmental factors, creating a safety culture, linking safety activities to accreditation and performance measures, developing and leading an interprofessional safety team, and using best practices.

ASHP's House of Delegates will convene as usual during the 2014 Summer Meetings.

ASHP’s House of Delegates will convene as usual during the 2014 Summer Meetings.

“Ideally, we’d like to see entire patient safety teams attend the meeting together,” said Abalos, noting the large array of collaborating partners in different disciplines, including organizations like the Institute for Safe Medication Practices, the American College of Physician Executives, and the Medication Safety Officers Society.

The new Informatics Institute will address emerging technology issues, such as the deployment of computerized prescriber order entry and ePrescribing. It targets pharmacists, pharmacy technicians, health information technology professionals, systems developers, policy-makers, consultants, vendor representatives, and other professionals involved in the collection and dissemination of health information.

Sessions at the new Pharmacy, Practice, & Policy meeting will revolve around leadership, operations and management, clinical practice, and policy and governance. It will also host ASHP House of Delegates activities.

Open Access

Each of the boutique meetings will have its own dedicated space for educational sessions, networking, and other activities, and each will have separate information desks and ASHP support staff.

The boutiques will also feature separate keynote speakers and websites. But the meetings are not exclusive. Regardless of which boutique attendees register for, they will still have unrestricted access to all sessions and events at any of the three specialized meetings.

The ASHP Summer Meetings will continue to host a common opening session, grand opening reception, and exhibit hall, along with a debut feature called ConnectLive.

ConnectLive is a groundbreaking way to network, create meaningful connections, and help meeting participants interactively solve some of the tough problems they face in their work.

“We know that attendees who come to these meetings want meaningful connections and to interact with peers who have common goals,” added Abalos. “We’re excited about this new format because we truly believe it will provide that special atmosphere.”

–By Steve Frandzel

March 12, 2014

Landmark Provider Status Bill Introduced in Congress

Filed under: Ambulatory Care,ASHP News,Clinical,Managers,Provider Status,Uncategorized — Kathy Biesecker @ 3:37 pm

A NEW PROVIDER STATUS BILL that extends pharmacists’ services to medically underserved areas of the country has received strong support from ASHP.

Introduced March 11, 2014, by Reps. Brett Guthrie (R-Ky.), G.K. Butterfield (D-N.C.), and Todd Young (R-Ind.), H.R. 4190 will amend the Social Security Act to recognize pharmacists as providers under Medicare Part B.

The change will help address gaps in the U.S. health care system by increasing access to pharmacists’ services for patients who live in medically underserved communities.

“This bill will make a tremendous difference to patients needing additional access to the critical health care services that pharmacists provide,” said ASHP CEO Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP.

H.R. 4190 will recognize licensed pharmacists working within their state pharmacy practice acts to deliver care for patients in federally defined medically underserved communities.

The legislation also establishes a mechanism to pay for pharmacist provider services as a percentage of the current physician fee schedule, or pursuant to pharmacist specific codes as part of that schedule.

“The ASHP Board of Directors made achieving provider status the Society’s top priority in our strategic plan, and we are extremely pleased to see that patients are one step closer to having the access they deserve to the patient care services of pharmacists,” said ASHP President Gerald E. Meyer, Pharm.D., M.B.A., FASHP.

“It is heartening to see that our elected officials in Washington appreciate the value pharmacists can bring as patient care providers, and we look forward to seeing this bill get passed and signed into law.”


February 4, 2014

Our Past Year and the Year Ahead

Filed under: Ambulatory Care,ASHP News,From the CEO,Quality,Regulation,Residents — Kathy Biesecker @ 12:40 pm
Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

I VALUE THE OPPORTUNITIES I have to meet with and talk to members. During my visits to state affiliate meetings, schools of pharmacy, and the hospitals and clinics where you practice, I enjoy hearing about the work that you are doing and seeing first-hand how your efforts benefit the patients under your care. These visits also give me a chance to update you on the initiatives that ASHP is undertaking on your behalf.

As I’m traveling, I am only able to talk to small groups of members. That’s why I am so excited to tell you about a recent interview I did with William A. Zellmer, M.P.H., for a podcast called “AJHP Voices.”

Bill, a former ASHP staff member who served as the Society’s Deputy Executive Vice President and editor of AJHP, hosts this podcast series, which features interviews on contemporary pharmacy issues and discussions with AJHP authors. The podcast gives me a chance to update an even larger audience about the work that is happening at ASHP.

During our interview, Bill and I recapped a few of the highlights of the Society’s important work in 2013, including our partnership in the Center for Pharmacy Practice Accreditation and our role in the successful passage of the Drug Quality and Security Act, legislation that addresses compounding outsourcing facilities.

We also looked forward to our plans for 2014. Bill and I discussed the upcoming Ambulatory Care Conference and Summit, along with our plans to meet the growing need for accredited residency sites and accredited technician training programs, and develop tools to help members expand pharmacists’ services to clinics and other ambulatory care clinics. There’s also a message directed to student pharmacists, residents, and new practitioners.

Bill and I talked quite a bit about ASHP’s top advocacy priority of achieving provider recognition for pharmacists, which was a major focus of our advocacy efforts in 2013. Last year, a 14-member stakeholder group from the major national pharmacy professional associations and chain pharmacies came to consensus around a set of principles to govern our legislative push for provider status.

This move sets the stage for building a strong, broad-based coalition in 2014 to draft and introduce legislation into Congress. It’s our hope that other health professions as well as patient and consumer groups, payers, business coalitions, state-based groups, and others will join our efforts to improve our nation’s health outcomes by bringing patients closer to the services that pharmacists provide.

We packed quite a bit into a brief interview! Please listen to the podcast for news on the work we are doing. And as we move forward, I appreciate your feedback on how you feel ASHP is meeting your professional needs. I hope to see and hear from you in 2014.

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