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expressed written consent of NIPCO/NCPA and the payment of appropriate fees is strictly prohibited by law.
Patient History/Data Base for Osteoporosis NAME: DATE:
RACE: GENDER: DOB:
MENSTRUAL HISTORY: AGE AT MENARCHE: AGE AT MENOPAUSE: TYPE OF MENOPAUSE: (circle one) NATURAL ARTIFICAL
HISTORY OF AMENORRHEA:
FAMILY HISTORY OF OSTEOPOROSIS:
BODY TYPE (weight/frame size):
CALCIUM INTAKE : AVERAGE DAILY DIETARY INTAKE:
CALCIUM SUPPLEMENT YES NO
PRODUCT:
DOSING REGIMEN:
SELF-REPORT OF ADHERENCE:
VITAMIN D INTAKE: SOURCE QUANTITY/DAY
MULTI-VITAMIN
MILK
VITAMIN FORTIFIED CEREAL
OTHER
DO YOU SMOKE/USE TOBACCO? YES NO IF YES, WHAT TYPE? HOW OFTEN?
DO YOU DRINK ALCOHOL? YES NO IF YES, WHAT TYPE? HOW OFTEN?
HISTORY OF FRACTURES—DATE:
SKELETAL SITE:
DEGREE OF TRAUMA:
FALLS—# OCCURANCES/MONTH:
HISTORY OF PROLONGED SEDENTARY PERIODS:
2
MEDICATION USE: DRUG DOSE DURATION
ORAL GLUCOCORTICOIDS
ANTICONVULSANTS
SEDATIVES
ANTINEOPLASTICS
ALUMINUM-CONTAINING ANTACIDS
THYROID HORMONE
MEDICAL CONDITIONS: MULTIPLE MYELOMA YES NO HYPERPARATHYROIDISM YES NO
HYPERTHYROIDISM YES NO
HYPOGONADISM YES NO
TYPE 1 DIABETES YES NO
RHEUMATOID ARTHRITIS YES NO
OBSTRUCTIVE JAUNDICE YES NO
SEVERE MALNUTRITION YES NO
ROUTINE EXERCISE: TYPE OF EXERCISE
TIMES PERFORMED/WEEK
DURATION OF PERFORMANCE
YEAR SUSTAINED PROGRAM STARTED
HISTORY OF BMD TESTING: DATE
SITE TESTED
RESULTS
3
Osteoporosis/Fracture Prevention Plan DATE: ____________ Calcium Intake
• Dietary plan:
• Calcium supplementation plan:
• Contraindications: yes no
• Recommended daily intake/allowance:
AGE ELEMENTAL CALCIUM MG/DAY
BIRTH–6 MONTHS 400
6 MONTHS–1 YEAR OLD 600
1–5 YEARS 800
6–10 YEARS 800-1200
≥11YEARS 1,200 – 1,500
CALCIUM SALT % ELEMENTAL CALCIUM
CA CARBONATE 40
CA CITRATE 21
CA GLUCONATE 9
CA GLUBRONATE 6.5
CA LACTATE 13
DIBASIC CA PHOSPHATE 23
TRIBASIC CA PHOSPHATE 39
CALCIUM PRODUCT
CALCIUM SALT
CALCIUM SALT MG/UNIT
ELEMENTAL CALCIUM MG/UNIT
RECOMMENDED UNITS/DAY
ACTUAL
EXAMPLE TUMS ULTRA® CALCIUM CARBONATE
1,000 400 3 TABLETS
4
Vitamin D Intake
• Current average daily intake/allowance:
• Recommended daily intake/allowance:
AGE VITAMIN D IU/DAY
BIRTH–50 YEARS OLD 200
51–70 YEARS OLD 400
>70 YEARS OLD 600
• Vitamin D supplementation plan:
Exercise • Patient education
⇒ What is weight-bearing exercise ⇒ Avoid immobility
Proposed Exercise Plan: Type of Exercise
Times Performed/Week
Duration of Performance
• Patients with known cardiovascular disease or men over 40 and women over
50 years of age with multiple cardiovascular risk factors should consult with a physician before beginning a moderate-intensity or greater exercise program.
• Patients with established osteoporosis need a physical examination prior to beginning an exercise program.
Smoking
• Cigarette smoker: yes no • Cessation plan:
5
6
Fall Prevention Counseling Guide
• Routine eye examination • Wear glasses? yes no
⇒ Do not attempt walking without glasses • Appropriate footwear
⇒ Comfortable, low heels ⇒ Sturdy
• Ensure main routes around home are free of obstacles ⇒ Remove electric and telephone cords ⇒ Remove or firmly anchor rugs
• Good lighting throughout • Handrails in bathroom, halls and stairs • Reduce slipperiness of bathtub and shower floors • Recent falls? yes no
Explain:
7
Osteoporosis Patient Monitoring
PATIENT NAME: DATE: SUBJECTIVE
CALCIUM INTAKE ADHERENCE TO DIETARY INTAKE PLAN:
ADHERENCE TO CALCIUM SUPPLEMENT REGIMEN:
SELF REPORT OF MISSED DOSES/WEEK:
REPORTED SIDE EFFECTS OR PROBLEMS:
EXERCISE EXPERIENCE TYPE OF EXERCISE
TIMES PERFORMED /WEEK
DURATION OF EACH PERFORMANCE
YEAR SUSTAINED PROGRAM STARTED
MEDICATION EXPERIENCE—DRUG REGIMEN
ADMINISTRATION TECHNIQUE:
ADHERENCE—SELF REPORT OF MISSED DOSES/WEEK:
EXPERIENCES—ADRS:
OTHER PROBLEMS:
FALL HISTORY DATE:
CAUSE OF FALL:
CONSEQUENCES:
CORRECTIVE ACTION:
DATE:
CAUSE OF FALL:
CONSEQUENCES:
CORRECTIVE ACTION:
DATE:
CAUSE OF FALL:
CONSEQUENCES:
CORRECTIVE ACTION:
QUALITY OF LIFE # DAYS OF WORK LOST IN PAST MONTH:
Bone Density Screening Supply and Equipment Checklist:
Ultrasonometer and all related supplies Operation manual Extension cords Outlet strips Water bottle Alcohol spray Cloth towels Paper towels Gloves Hand sanitizer
General Supplies: Nametag Lab coat Garbage can Garbage can liners Consent Forms Result Forms Educational Materials Product Samples Educational brochures Cash box/cash Receipts Clipboards Pens Poster Putty Duct tape Scissors Stapler Masking/scotch tape Optional: small clock Optional: tissues Optional: Breath mints
11
Bone Density Consent Form
Name ____________________________________ Male Female Date ________________________ (please print) Address ___________________________________City __________________________________________ State ________ ZIP ____________ Telephone _________________ Date of Birth___________ Age_______ Physician ___________________________Address _____________________________________________ Have you been diagnosed with osteoporosis? Yes No Have you ever had a hip/spine or full body bone density test? Yes No If you answered “yes” to the questions above, a bone density screening may not be right for you. Please ask the technician for more information.
Do you have risk factors? Indicate (√) if you are or you have any of the following: A personal history of fracture as an adult. A history of fracture in first-degree relative (e.g., mother, father, sister, brother only). Caucasian Race. Female gender. Poor health/ frailty. Current cigarette smoking. Low body weight (Less than 127 lb.). Low calcium intake (lifelong). Excessive alcohol intake or alcoholism. Impaired eyesight despite adequate correction. Recurrent falls. Sedentary lifestyle or inadequate physical activity. Chronic diseases such as rheumatoid arthritis, multiple sclerosis, COPD, hyperparathyroidism, etc.
Please specify: ___________________________________________________________ Drug therapy affecting bone health such as anticonvulsants, cytotoxic drugs, excessive thyroxine,
glucocorticosteroids (i.e. prednisone, cortisone), heparin, lithium, etc. Please specify: ________________________________________________________________________
For Women Only:
Do you have an estrogen deficiency in that you have experienced one of the following? o Early menopause before age 45 and are not on estrogen replacement; o Removal of both ovaries and are not on estrogen replacement; o Prolonged absence of menstrual cycle (greater than 1 year) before menopause; o Menopause and are not on estrogen replacement.
AUTHORIZATION & RELEASE: I understand this is a screening and is not meant to substitute for health care offered by my physician or other health care provider. I, intending to be legally bound, hereby release all health care personnel, ______________Pharmacy®, and all sponsoring agencies from all responsibility in connection with the screening. I understand that the screening results will be provided to me and that I am responsible for any follow-up with my physician. I understand that these results may be sent to my physician named above and maintained by ________________Pharmacy® as part of a confidential record and may be included in a summarized format or statistical analysis for group data. I have read and understand this Authorization and Release.
SIGNATURE OF PATIENT or CAREGIVER DATE ACKNOWLEGEMENT OF NOTICE OF PRIVACY PRACTICES: I have received a copy of the _______________Pharmacy® Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by __________Pharmacy® and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
CPT Codes for Medication Therapy Management and Monitoring Medication Therapy Management Service Codes (MTMS) Medication Therapy Management Service(s) (MTMS) describe face-to-face patient assessment and intervention as appropriate, by a pharmacist. MTMS is provided to optimize the response to medications or to manage treatment-related medication interactions or complications.
MTMS includes the following documented elements: review of the pertinent patient history, medication profile (prescription and non-prescription), and 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. 0115T Medication therapy management service(s) provided by a pharmacist, individual, face-to-face
with patient, initial 15 minutes, with assessment, and intervention if provided; initial encounter 0116T subsequent encounter + 0117T each additional 15 minutes (List separately in addition to code for the primary service)
(Use 0017T in conjunction with 00115T, 00116T)
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Selected ICD-9 Codes for Osteoporosis Condition Code
Medication adherence assessment, education, and monitoring
Osteoporosis screening (BMD test)
GOALS OF SERVICE REQUESTED:
Number of Authorized Visits:
I consider these requested services to be a necessary part of the patient’s care for the following reason: New diagnosis Change in symptoms or condition which necessitates change in self-management or Re-education or refresher training
__________________________________ ________________ Physician’s Signature Date
PHYSICIAN NAME (PRINT): ____________
PRACTICE ADDRESS: _____ TELEPHONE: ___ PIN/NPI: _____ ____________
3. PATIENT’S BIRTH DATE
6. PATIENT RELATIONSHIP TO INSURED
8. PATIENT STATUS
10. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. AUTO ACCIDENT?
c. OTHER ACCIDENT?
10d. RESERVED FOR LOCAL USE
1a. INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (INCLUDE AREA CODE)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
b. EMPLOYER’S NAME OR SCHOOL NAME
c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.
SEX
F
HEALTH INSURANCE CLAIM FORMOTHER1. MEDICARE MEDICAID CHAMPUS CHAMPVA
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.
MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
19. RESERVED FOR LOCAL USE
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)
17a. I.D. NUMBER OF REFERRING PHYSICIAN
FromMM DD YY
ToMM DD YY
1
2
3
4
5
625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)
SIGNED DATE
32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERERENDERED (If other than home or office)
SIGNED
MM DD YY
FROM TO
FROM TO
MM DD YY MM DD YY
MM DD YY MM DD YY
CODE ORIGINAL REF. NO.
$ CHARGES EMG COBRESERVED FOR
LOCAL USE
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$ $ $
33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE& PHONE #
PIN# GRP#
PICA PICA
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
YES NO��
( )
If yes, return to and complete item 9 a-d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
20. OUTSIDE LAB? $ CHARGES
22. MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
CA
RR
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PA
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AN
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SU
RE
D IN
FO
RM
AT
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PH
YS
ICIA
N O
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PL
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YES NO
YES NO
1. 3.
2. 4.
DATE(S) OF SERVICE Typeof
Service
Placeof
Service
PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)
PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM CMS-1500 (12/90), FORM RRB-1500,APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
SAMPLE
16
Osteoporosis Management and Screening Service Business Plan Services Planned Goals of Service(s) Target Start Date: To be Done Implementation
Timeline Anticipated Cost
Assigned To/
Comments
Regulatory Considerations Machine registration and fees Y N
Site Development and Preparation Location for screenings and other services Y N
Remodeling Y N
Furniture Y N
Equipment Y N
Supplies Y N
In Store Logistics Patient care documentation system Y N
Pharmacist staffing Y N
Staff incentives Y N
Training of employees Y N
Advertising and Promotion In-store Y N
Patient – In store identification Y N
Patient – Direct mail Y N
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Advertising and Promotion Physician – Direct mail
Targets:
Y N
Physician – Detailing
Targets:
Y N
Other referral sources Y N
Website Y N
Other: Y N
Reimbursement Determine screening fees Y N
Determine method for collecting payment from patient Y N
Method for filing and tracking claims (billing software or service) Y N
Financials Return on investment analysis Y N Tracking revenue and service delivered Y N Evaluation of Service(s) Revenue targets Y N
Patient goals Y N
Other: Y N
Ongoing Operations Policy and procedure manual Y N
BMD machine calibration Y N
Advertising and promotion Y N
Scheduling screening events Y N
18
Return on Investment Analysis Direct Expenses Year One Year Two
Remodeling
Furniture Equipment Supplies
Patient care documentation system
Pharmacist staffing
Staff incentives
Training of employees
Advertising and promotion
Indirect Expenses Year One Year Two
Overhead attributable to program [%sq ft of space x % of time used = % of total store overhead or percentage of total sales attributable to program = % of total
store overhead]
Total Expenses
Direct Revenue Year One Year Two Prescription Revenue Year 1: ____ new osteoporosis prescriptions x 12 fills x $ __ gross profit/fill Year 2: ____ new osteoporosis prescriptions x 12 fills x $ __ gross profit/fill
Professional/Screening Fees Year 1 ____ patient screenings at $___ ____ patient management visits at $___ Year 2 ____ patient screenings at $___ ____ patient management visits at $____
Total Direct Revenue
Indirect Revenue Year One Year Two
_____ % of screening customers will buy calcium supplements Year 1 __ customers buying calcium x $__ gross profit x 12 purchases/yr Year 2 __customers buying calcium x $__ gross profit x 12 purchases/yr
Total Indirect Revenue
Total Revenue
Profit
19
Sample Patient Dialog on BMD Test Results Sally Smith, a 48 year-old female, participated in a BMD screening and wanted to know the results once it was complete. The following could be discussed with her: Sally, your T-score results from your ultrasound screening are a -1.68. This puts you at medium risk for osteoporosis. You also have 4 risk factors (female, Caucasian, low calcium intake and post menopausal) which, together with your T-score, may further increase your risk for osteoporosis-related fractures. I would recommend you take this information to your next appointment and discuss your results with your physician. Your physician might decide you need to also have a hip and spine test, which is considered to be the gold standard to determine your true risk level for fracture. In the meantime, it is important to be sure you are getting 1,000 – 1,500 mg of calcium plus 200 I.U. vitamin D per day in your diet or through vitamin supplementation as well as performing weight bearing exercises, such as walking, to reduce future bone loss.