Pharmacy Revenue Cycle Management Certificate

This self-paced, online professional certificate is designed for pharmacists and pharmacy technicians who are interested in expanding their knowledge and skills in pharmacy revenue cycle management.

Overview Including Cost and Revenue Cycle

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This activity provides an overview of the pharmacy revenue cycle and key CMS policy and payment information.

• Contrast the information required to bill a drug on a hospital UB-04 (837I) for an inpatient claim vs. an outpatient claim.
• Assess how at least one U.S. act regulates hospital system billing.
• Apply the correct code set for a pharmacy billing situation.
• Identify chapters in the CMS internet-only manual (IOM) 100-04 (Medicare Claims Processing Manual) that pertain to drug billing in the hospital setting.
• Use the CMS policy / payment information that is posted quarterly.
• Design a list of NDC numbers that are designated as “Unapproved drug for use in drug shortage” in the Food and Drug Administration (FDA) National Drug Code (NDC) Directory.
• Interpret the Medicaid Drug Rebate Program Data to find which NDC numbers are listed with a clotting factor indicator.

Medicare Rules and Regulations

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This activity discusses Medicare and Medicaid programs including eligibility, funding sources, and drug categories.

• Differentiate Medicare and Medicaid programs as to which patients are eligible and funding sources.
• Compare the eligibility criteria for each of three groups who are eligible for Medicare.
• Compare your state’s MAC assignments for A/B MACs, Home Health MACs and DME MACs.
• Distinguish four drug categories where payment is made under Part B or Part D depending upon the drug’s indication.
• Determine which revenue codes crosswalk to the primary cost center of "Drugs Charged to Patients" using the Medicare revenue cost center crosswalk published with each year's OPPS proposed rule.

Medicare Billing

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This activity provides an overview of the outpatient and inpatient Medicare reimbursement model.

• Describe the Medicare outpatient reimbursement model.
• Identify key Medicare rules and policies impacting outpatient billing.
• Evaluate methods for optimizing revenue management in the outpatient setting.
• Describe the Medicare inpatient reimbursement model.
• Identify key Medicare rules and policies impacting inpatient billing.
• Evaluate methods for other service locations in regards to reimbursement and billing.
• Compare various types of billing models used in telehealth pharmacy care.
• Differentiate the code sets for telehealth pharmacy care billing.

Revenue Cycle Building Blocks and Formulary Decision Making

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This activity describes roles and responsiblities of key stakeholders, and mechanics of the pharmacy revenue cycle including standards of participation for health systems.

• Define roles and responsibilities of key healthcare and pharmacy revenue cycle stakeholders.
• Discuss the mechanics of the pharmacy revenue cycle.
• Apply resources and methods for ensuring accurate and up-to-date charging for medications.
• Select medications for formulary vs. non-formulary status.
• Differentiate between billing and reimbursement practices for patient home medications and hospital-provided medications.
• Justify situations where the billing of part D is appropriate.
• Outline standard conditions of participation for health systems when caring for Medicare beneficiaries.

Denials, Appeals, Edits, and Calculating Reimbursement

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This activity covers common denial types, strategies to appeal a denied claim, and payment models related to insurance contracts.

• Differentiate between common denial types.
• Apply strategies to successfully appeal denied claims to a patient case.
• Outline methods for system pre-bill process changes to mitigate future denials.
• Develop a plan for pre-payment reviews and agency audits.
• Explain CMS billing requirements for drugs obtained through the 340B federal drug pricing program.
• Arrange payment models related to insurance reimbursement contracts.
• Analyze the status of claims based on a remittance advice (RA).
• Develop an appropriate response to a targeted probe and educate (TPE) audit results from your MAC.

Billing for Clinical Pharmacy Services and Collaborative Practice

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This activity describes key stakeholders and requirements for establishing a billable pharmacy service to various case settings including physician-based and hospital-based clinics.

• Describe internal and external key stakeholders when establishing a billable pharmacy service.
• Define incident-to requirements in physician-based and hospital-based clinics.
• Apply evaluation and management CPT code billing rules in patient cases.
• Explain requirements for facility fee billing.
• Apply billing rules and opportunities to various case settings.

Additional Billing Opportunities and Value-Based Care

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This activity covers billing opprotunities in a physician practice and pharmacy initiatives related to value-based care.

• Design a work plan for pharmacist completed Medicare Annual Wellness Visits in a physician practice.
• Analyze the requirements for billing for Transitional Care Management within a collaborative team in a physician practice.
• Evaluate the components to bill Medicare Chronic Care Management codes in a physician practice.
• Identify other billing opportunities within a physician practice.
• Propose other billing opportunities within a physician practice.
• Create an assessment of possible pharmacy initiatives related to value-based care opportunities within a health network.  

Using Claims Data to Improve Revenue Capture and Patient Care

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This activity describes publically available information including data files to understand reimbursement calcuations and, potential benefits from merging clinical and financial data points.

• Explain how to use publically available data files to better understand reimbursement calculations.
• Interpret remittance advice data information.
• Analyze charge to cost and reimbursement limits.
• Describe potential reasons for an imbalance between purchasing and billing data elements.
• Assess drug waste billing opportunities and required components.
• Evaluate the potential benefits from merging clinical and financial data points.

Pharmacy Operational Impact and Entrepreneurial Opportunities

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This activity describes the pharmaict's role in charge capture, coding and documentation, and a pharmacist-led revenue cycle department.

• Describe methods that exist for charge capture.
• Review the importance of timely and accurate coding and documentation.
• Identify processes that can be used for ensuring integrity of charge generation.
• Analyze current administrative and policy decisions by payers impacting pharmacy operations.
• Review impact of site-of-care changes and plan shifting in the healthcare marketplace.
• Apply principles from part 1 and part 2 of the presentations Pharmacy and Other Clinical Operational Impact to identify charge errors.
• Identify non-pharmacy stakeholders in the revenue cycle process and how their roles ensure appropriate reimbursement for drugs.
• Categorize tasks within revenue cycle that could be delegated to a pharmacy technician under the supervision of a pharmacist.
• Design a checklist to analyze areas of opportunities where drug charges are not billed on the final claim.
• Construct a grid to track denials and appeals to demonstrate ROI for a pharmacist-led revenue cycle department.
• Design a job description for a pharmacist who directs revenue cycle management for a hospital system.

In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing Education, ASHP requires that all individuals in control of content disclose all financial relationships with ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship with ineligible company in any dollar amount in the past 24 months and the educational content that the individual controls is related to the business lines or products of the ineligible company. 

An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed to the activity audience. 

•          No one in control of the content of this activity has a relevant financial relationship (RFR) with an ineligible company.

As defined by the Standards of Integrity and Independence definition of ineligible company. All relevant financial relationships have been mitigated prior to the CPE activity.

This online activity consists of a combined total of 9 learning modules. Pharmacists and pharmacy technicians are eligible to receive a total of 17.5 hours of continuing education credit by completing all 9 modules within this certificate. 

Participants must participate in the entire activity and complete the evaluation and all required components to claim continuing pharmacy education credit online at ASHP Learning Center. Follow the prompts to claim credit and view your statement of credit within 60 days of completing the activity. 

Important Note – ACPE 60 Day Deadline: 

Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. To verify that you have completed the required steps and to ensure your credits have been reported to CPE Monitor, check your NABP profile account to validate that your credits were transferred successfully before the ACPE 60-day deadline. After the 60-day deadline, ASHP will no longer be able to award credit for this activity.