Free BCACP Ambulatory Practice Business Models Questions and Answers — Questions and Answers
Question 1: An ambulatory care pharmacist works in a physician's office and provides follow-up visits for established patients with hypertension. To bill for these services as "incident-to" the physician under Medicare Part B, which of the following conditions is required?
- The physician must co-sign every pharmacist-written note within 24 hours.
- The pharmacist must have their own unique provider transaction access number (PTAN).
- The physician must be physically present in the office suite when the pharmacist provides the service. (Correct answer)
- The patient must be seeing the pharmacist for the initial visit to establish the plan of care.
Correct answer: The physician must be physically present in the office suite when the pharmacist provides the service.
Medicare's "incident-to" billing rules require direct supervision, which is defined as the physician being physically present in the office suite and immediately available to provide assistance. The service is billed under the physician's NPI, not the pharmacist's. The physician must perform the initial service to establish the diagnosis and plan of care, and the pharmacist's service must be an integral part of that ongoing plan.
Question 2: An ambulatory care practice is transitioning from a fee-for-service to a value-based care model. Which of the following key performance indicators (KPIs) would be most important to track to demonstrate the practice's success under the new model?
- Increase in the total number of patient visits per month.
- Reduction in 30-day hospital readmission rates for managed patients. (Correct answer)
- Maximization of revenue generated from ancillary services.
- Decrease in the average length of a patient appointment.
Correct answer: Reduction in 30-day hospital readmission rates for managed patients.
Value-based care models incentivize quality of care and improved patient outcomes over quantity of services. Reducing hospital readmission rates is a key quality metric that demonstrates better management of chronic conditions and directly leads to significant cost savings for the healthcare system, aligning perfectly with the goals of value-based care. The other options are more aligned with a fee-for-service model that prioritizes volume and revenue per encounter.
Question 3: A pharmacist in a primary care clinic spends 25 minutes during a calendar month providing non-face-to-face care coordination for a Medicare patient with type 2 diabetes and heart failure. This includes telephone calls and medication reconciliation. Which CPT® code is the most appropriate to bill for these services?
- 99211 (Level 1 E/M Office Visit)
- 99605 (MTM Service, Initial)
- 99491 (CCM, 30 min by Physician/QHP)
- 99490 (Chronic Care Management, First 20 min) (Correct answer)
Correct answer: 99490 (Chronic Care Management, First 20 min)
CPT® code 99490 is designated for at least 20 minutes of clinical staff time per calendar month for non-face-to-face Chronic Care Management (CCM) services for patients with two or more chronic conditions. Since the pharmacist spent 25 minutes, this code is appropriate. 99211 is for a face-to-face visit. 99605 is for an initial MTM encounter. 99491 is for at least 30 minutes of time spent personally by a physician or other qualified healthcare professional, not clinical staff.
Question 4: When presenting a business plan to hospital administration to justify the creation of a new pharmacist-led transitional care management (TCM) service, which of the following provides the strongest argument for a positive return on investment (ROI)?
- Projected number of patients enrolled in the first year.
- High patient satisfaction scores reported on post-discharge surveys.
- The number of medication discrepancies identified and resolved by the pharmacist.
- Demonstrated cost avoidance through a reduction in preventable hospital readmissions. (Correct answer)
Correct answer: Demonstrated cost avoidance through a reduction in preventable hospital readmissions.
While enrollment numbers, satisfaction scores, and process measures are important, the most compelling metric for demonstrating financial ROI to administration is cost avoidance. Reducing costly, and often penalized, hospital readmissions provides a clear and significant financial benefit that can be directly compared against the operational costs of the new pharmacy service.
Question 5: A 75-year-old patient is discharged from the hospital on a Thursday following an admission for a COPD exacerbation. To meet the requirements for billing Transitional Care Management (TCM) services, the ambulatory care pharmacist must make initial interactive contact (e.g., by telephone) with the patient or caregiver no later than when?
- The following Monday. (Correct answer)
- Within 7 calendar days of discharge.
- At the time of the face-to-face visit.
- The same day as discharge.
Correct answer: The following Monday.
TCM guidelines require that the initial interactive contact with the patient and/or caregiver must occur within two business days following discharge. Since the patient was discharged on a Thursday, the first business day is Friday and the second is the following Monday. Contact must be made by the end of the day on Monday.
Question 6: Which of the following is a mandatory component that defines the scope of a pharmacist's authority within a collaborative practice agreement (CPA)?
- A formulary of preferred medications the pharmacist must use.
- The specific drug therapy management functions the pharmacist is authorized to perform. (Correct answer)
- The fee schedule for services provided by the pharmacist.
- A list of the pharmacist's professional liability insurance policy details.
Correct answer: The specific drug therapy management functions the pharmacist is authorized to perform.
The fundamental purpose of a CPA is to legally define the extent of the pharmacist's role. This must include a clear description of the duties and prescriptive authority being delegated, such as the types of diseases to be managed and the drug therapy the pharmacist can initiate, modify, or monitor. While other elements like insurance or payment may be part of a larger business arrangement, they are not the core legal components defining the scope of practice within the CPA itself.
Free BCACP Ambulatory Practice Business Models Questions and Answers
An ambulatory care pharmacist works in a physician's office and provides follow-up visits for established patients with hypertension.
To bill for these services as "incident-to" the physician under Medicare Part B, which of the following conditions is required?