THE UNIVERSITY OF NEW MEXICOCOLLEGE OF PHARMACY

ALBUQUERQUE, NEW MEXICO

The University of New Mexico

Correspondence Continuing Education Coursesfor

Nuclear Pharmacists and Nuclear Medicine Professionals

VOLUME V, NUMBER 5

Pharmaceutical Care:SOAPing a Consult in Diagnostic Imaging

by:

Michael P. Kavula, Jr., Pharm.D., BCNP

Supported by aneducational grant from: ~~mersham HEALTHCARE

● m Ike IJnivc~iw of Ncw Mexico College of WamUGY is aI~PIUV~ by he Afncrican ~C)un~il 011 l%a~a~euticnl ~ucntio~ us u provi(ler of co~linuing

phnlmaccuti.al education. l’rogmn No, 039-000-95-003-HM. 2,5 Contict Hours or .?5 CEU’s

m

Coordinating Eddor

and

~“rector of Ptirmucy Coti”nuing Educdion

William B. Hladik III, M. S., R. Ph.College of Pharmacy

University of New Mexico

ksociate ~itor and Production Spectiist

Sharon [. Magers Ramirez, Adm. Asst. 11

College of PharmacyUniversity of New Mexico

Editoti Board

George H. Hinkle, M. S., R.Ph., BCNP

William B. Hladik 111,M. S., R. Ph.Jeffrey P. Norenberg, M. S,, R.Ph., BCNP

Laura L, Boles Ponto, Ph. D., R. Ph.Timothy M, Quinton, Pharm.D., M. S., R.Ph., BCNP

Gu~t Reviewer

Stanley M. Shaw, Ph.D.

While the advice and information in this publication arc believed to be true tind accurate tit press time, neither the atithor(s) nor the editor nor thepublisher can a-t any legal responsibility for any errors or omissions that may be made. The publisher mtikes no warranty, express or implied,with respect to the material contained herein.

Copyright 1996University of New Mexico

Pharmacy Continuing Education ●Albuquerque, New Mcxic{]

PHARWCEUTICAL CARE: SOAPING A CONSULT IN DIAGNOSTIC IMAGING

STATEMENT OF OB~CTIVES

The primary purpose of this lesson is to provide a fundamental understanding of the development of a written

consult to a health care provider. To accomplish this, the pharmacist must review patient data to determine whatis to be included in the patient problem list. From this list, and from a knowledge of what diagnostic imagingprocedure w ordered, the nuclear pharmacist will be shown how to make an assessment and a plan for the desired

diagnostic/therapeutic outcome. Formulating a written response in SOAP (Subjective Data, Objective Data,Assessment, Plan) form is essential for communicating with health care providers and will assist in reimbursement.

Upon completion of tltis article tize reader slcould he able to;

1. define ‘patient problem list.’

2. describe the components of a SOAP Note.

o3. develop a problem list for a patient scheduled to undergo a diagnostic imaging procedure.

4. make an assessment of the pati ent’s problem list, relative to the imaging procedure ordered.

5. determine if there is a potential for drug-drug interactions, drug-procedure interactions, etc.

6. write a pharmaceutical care plan recommendation in SOAP format.

1

COURSE OUTLINE

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~TRODUCTION

THE PHARMACEUTICAL CAREAPPROACH

EFFECTING PROACTWE CHANGE

PROBLEM LIST

SOAP NOTE

A. Subjective DataB. Objective Datac, AssessmentD. Plan

CONTR~UT~G TO PATENT CARE

A. Consults Unrelated to DiagnosticImaging

B, Pharmaceutical Care and Diagnosticimaging

REIMBURSEMENT FOR COG~TIVESERMCES

CONCLUSION

PHARMACEUTICAL CARE:SOAPING A CONSULT IN DIAGNOSTIC

IMAGING

by:

Michael P, Kavula, Jr., Phmm.D., BCNP

Mercer University Southern

School of PharmacyAtlanta, Georgia

~TRODUCTION

Surveys of nuclear pharmacists’ attitudes toward

their jobs and responsibilities document the potential

untapped availability of the nuclear pharmacist as a

consultant. 1’~’3These studies demonstrated that the

nuclear pharmacist is a team player willing to offer

assistance but at the same time having a limited

opportunity to do so. Of significance was the fact

that professional interaction was the most appealing@

part of their practice, Rhodes et al. noted that

regardless of the practice setting, nuclear pharmacists

spend less than 200/0 of their time engaged in clinical

activities,3

Historically, community and hospital pharmacists

have been oriented toward the drug product withlittle or limited contact with patients and other healthcare professionals. Although nuclear pharmacists inthe hospital/clinic setting have the potential for directpatient contact, the lack of publishedpharmacist-patient encounters suggest that this classof professional is also oriented toward the drugproduct, Consultant services that are offered in thisenvironment are usually retrospective in nature. Thenuclear pharmacist is consulted when a diagnosticimaging procedure goes awry and the possibility toaffect a positive patient outcome has already passed.This type of interaction, although appreciated bypracticing nuclear pharmacists,’ does not have any

direct, positive outcome on patient care. In addition,because of the timing of this intervention, it does notsatisfy the definition of “pharmaceutical care” anddoes not qualify for reimbursement for the cognitive

o

service,

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THE PHARMACEUTICAL CARE APPROACH

Clinically involved pharmacists practicing in areas

osuch as pharmacokinetics, nutritional support andsome medical subspecialties have been makingpositive impact on patient care even before the term“pharmaceutical care” was ever used. Pharmacistswho practice as drug information specialists or areactively involved in drug outcome evaluation (DOE)studies also serve as consultants, but their input indirect patient care has been somewhat distant.’sHowever, the introduction of the “pharmaceuticalcare” concept by Hepler and StrandGand the attendant“Mediation Related Problems” (MRPs) now allowsthe pharmacist to become a proactive member in thepatient care arena. Some examples of MRPs basedon this author’s clinical experiences are iIllustrated inTable 1.

These examples are typical of what a pharmacistcan find if the effort is made to search for MRPs.Therapeutic drug MRPs 1, 3, 4, 5, 7, and 8 wereidentified by pharmacists who then intervened andoffered corrective solutions that were accepted. Thediagnostic drug examples illustrate how easily the~Ps can be adapted to diagnostic drugs. The goal

●in diagnostic imaging is that the procedure must offervaluable information for the care of the patient. Thepharrnaceutiml care approach should focus on ~sthat may produce a suboptimal test and ultimately asuboptimal patient outcome through delayed, absentor erroneous diagnostic imaging results.

In order to perform pharmaceutical care in themanner theorized by Hepler and Strand, patientspecific information is required. This presents aproblem for the nuclear pharmacist practicing in acentralized (commercial) nuclear pharmacy (CNP) orin the drug information center. It is probably this factmore than any other that has resulted in articlesstating that the nuclear pharmacist is performingpharmaceutical care when drug distribution functionsare performed correctly.7’*However, an acceptance bythe pharmacist to assume responsibility for theoutcome of the patient’s drug therapy along with theproactive interaction with patients, physicians, nursesor other health care professionals is mandatory for theperformance of pharmaceutical care. This interactionwith a caring attitude and the ability to positively

●contribute to patient care, comprise the necessaVingredients of the pharmaceutical care process,

Demographically, patient contact is greatest in thecommunity pharmacy or the ambulatory care clinic.

It is less so in the CNP but with electronic means(e.g., fw, e-mail) it is still possible for the nuclearpharmacist, by obtaining patient specific information,to offer expertise to pharmacists or other health careproviders in client institutions. The concept of“being there” will still be important and it behoovesthe nuclear pharmacist (academic and community) toexplore avenues of communication with the medicalstaff. Attending and/or sponsoring grand rounds,tumor board, monthly department meetings,Pharmacy and Therapeutic Committee meetings,assisting in the design of imaging protocols, androunding with pharmacist clinicians are some ways inwhich this can be accomplished.

From a practice perspective, it is impossible andperhaps unnecessary to offer pharmaceutical care forevery patient undergoing a diagnostic imagingprocedure, but selected patient data can be reviewed1-2 days prior to the procedure to determine ifintervention is necessary. Patients at risk, or whosedisease usually presents with concurrent medicalproblems requiring treatment are prime candidates.Table 2 lists five major disease categories andnuclear medicine procedures commonly performed inthese patients. In each disease category, imagingprocedures are utilized to diagnose or stage disease,and/or evaluate the pharmacological and surgicaltreatments the patient has undergone. These types ofpatients/imaging procedures offer the most “fertile”ground in which to initiate the pharmaceutical careprocess.4 Another approach would be to reviewpatient specific data for patients undergoingprocedures in which an MRP may place the patient atan additional risk, Table 3 lists some typicalexamples,

EFFECT~G PRO-ACTIVE CHANGE

Communication, verbal and written, in theappropriate format is the essence of having a positiveimpact on patient care. In 1964, Lawrence E. Weedpublished the problem-oriented approach to patientcare.g The pharmacist who is interested in practicingpharmaceutical care should be encouraged to adoptthis method. Physicians approach the patient withthis method and, when a pharmacist wants tocommunicate with a health care professional,adoption of Weed’s method facilitates the process.Other pharmacist clinicians have modified thisapproach and have developed the FARM (Findings,Assessments, Recommendations or Rational,

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Monitoring) notes and described in detail a objectively verifiable. Subjective data is most often

systematic approach to solving MRPS. ‘0”1“2 Common obtained by talking to or observing the patient.

to all these methods is the ~obfe~ List and SOAP

● Note. OBJECTIVE (0) DATA

PROBLEM LIST

The problem list is composed of patient and healthprofessional concerns. It can contain items in whichthere are surgical, pharmacologic or societalsolutions. A typical problem list contains patientcomplaints, abnormal lab values, unusual physicalfindings, which will aid in the diagnosis andmanagement of the disease. All too often,pharmacists will make judgments on a patient’s list ofmedications without the assistance of a problem listfor the patient. Only after the pharmacist hasknowledge of the patient’s working diagnosis andother related problems as documented in the problemlist, will he or she be able to make judgment onpotential or real medication-related problems. Whilethe physician’s use of the problem list usuallyinvolves reference to medical/surgical problems (e.g.,diabetes mellitus, hyper-tension), this concept wasused by Hepler and Strand in the development of the

● eight types of medication related problems that arelisted in Table 1 with examples.

SOAP NOTE

Each professional who documents his/her care in

the patient’s medical record uses the

problem-oriented SOAP Note as the method of

communication. For each problem the subjective

and Qbj ective data are recorded, an ~ssessment

performed, and a Elan formulated to correct the

problem.

SUBJECTIVE (S) DATA

The subjective section contains patient complaints,along with appropriate observations from health careprofessionals, In a diabetic patient with a foot ulcer,the subjective note may read:

s: “My right foot is swollen and the sore will

not heal. ” Compliant with insulin regimen,

but does not follow diet and exercise

recommendations.

in general, this data is not measurable or

Vital signs, lab results, imaging results, EKGs, etc.are included in the objective data section. For ourdiabetic patient with the foot ulcer:

o: Diabetes mellitus x 15 years

Right foot lesion appears swollen, red, bonemay be involved. No foul smell, slightdischarge on compression.Blood glucose = 175 mg/dL on admissionTemperature = 10O°F on admissionLungs: clearAbdomen: soft, non-tenderExtremities: no edema; swollen right foot

The data included in the objective section aremeasurable and thus verifiable.

ASSESSMENT (A)

The clinician now reduces the data from theobjective section (some of which may be problems)and assesses it while also taking into account theinformation recorded in the subjective section, Atthis point, the health care provider will make anassessment of the situation and write, for example:

A: 1) Diabetes mellitus2) Right foot ulcer3) Cellulitis vs Osteomyelitis

Performing the assessment, the caregiver deter-mines whether the health problem is stable(diabetes mellitus, compliant with insulin regimen)or is unstable (right foot ulcer, cellulitis vsosteomyelitis),

In this section the pharmacist evaluates the pa-tient’s drug regimen using his or her knowledgeand the eight MRPs as a foundation for thethought process, It is the assessment that supportsthe recommendation made in the Plan,

PLAN (P)

in the medical setting, the plan includes a sug-gested treatment, monitoring parameters, possibletherapeutic end points, patient education,

7

recommendations and any additional diagnostic datathat must be obtained. in our diabetic patient, forexample, the plan may be as follows:

P: 1) Insulin, sliding scale2) Culture foot wound3) Antibiotics: vancomycin, gentamicin,

peak and trough around third dose4) Three phase bone scan5) CBC, SMA-12, glycosylated

hemoglobin (HbA,C)6) Refer to certified diabetic educator

(CDE) for patient educationregarding diet and exercise

In recommending a Plan the caregiver determinesif a problem is “stable” and care can continue asbefore or if additional data is necessary to supportdifferent treatment. In the example Elan, item 1directly addresses the diabetes mellitus (but alsoimplies the physician wants tighter control); items 2,3, and 4 address the ulcer and cellulitis vsosteomyelitis+ The additional laboratory studiesordered (item 5) will check for elevated white bloodcells (infection), electrolyte balance (which can beaffected by diet and disease), and verification that theunderlying disease (diabetes mellitus) was/was notadequately controlled over the past few months(HbA,C). Item 6 addresses the patient’snoncompliance with diet and exercise therapy.

When providing pharmaceutical care, it is in thissection where the pharmacist recommends drugs,dosages, schedules and monitoring parameters.Additional examples of case studies in SOAP formatare available in the publication by Hart et al.g

CONTRIBUT~G TO PATlENT CARE

Most physicians will accept or consider apharmacist’s input in the care of a patient if it isoffered in a manner that indicates caring and makesa positive contribution to the overall care of thepatient, It must be remembered though, that as aconsultant, your recommendations will be eitheraccepted, modified, or rejected. ‘-3In any case, it isthe SOAP Note that is used as a vehicle to effectpositive patient care outcomes.

CONSULTS UNRELATED TO DIAGNOSTICIMAGING

The SOAP format is used as described or some-times modified to suit a particular situation. @

Experience has shown that as caregivers becomemore specialized, the SOAP N{~le is modified incontent and style to fit the particular situation. In ourdiabetic case example, a vascular surgeon who isconsulted to advise on the vascular viability of theright foot will not go into the treatment of thediabetes mellitus but will only be concerned withhis/her specialty area, Likewise, if the pharmacistdoes not participate in patient rounds, but insteadmonitors selected drugs, the “subjective” portion ofthe note can be deleted and patient specificinformation placed in the Objective section, For thisreason, clinicians sometimes use an abbreviatedSOAP Noie to suit their particular situation,

The following is a review of some therapeutic drugconsults to help one understand the process that isinvolved in effecting patient outcomes. It isimportant that the working relationship establishedwith other professionals be one that is nurtured inprofessionalism and trust.

Patient A: 49 year old (y/o) black female with●cancer of unknown pl+ima~. Status/Post (S/P)cholecystectomy. Two weeks later she presents withfever over 101‘F and a suspected biliary treeinfection, The Infectious Disease (lD) physician isconsulted and antibiotics prescribed, About twoweeks later, with no real change in her status, she isplaced on imipenem/cilastatin (Primaxin@) 500 mgiv. q6h. Her problem list includes multiplemetastatic sites, decreased albumin and total protein,and persistent fever greater than 10O°F. Hermedications include morphine for pain anddiphenhydramine to induce sleep,

The antibiotic regimen was discussed with thesenior partner of the oncology group, along with theoncologist caring for the patient, The addition of alipid-soluble antibiotic was suggested by thepharmacist in this situation. The attendingoncologist requested that the pharmacist write a noteto the lD physician.

Pharmacv ~o nsult:o

0: S/P cholecystectomy with temperaturegreater than 10O°F. Increased serum

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Now on Primaxin@ 500 mg iv. q6h.

A: With decreased liver function,imipenem/cilastatin will be primarily renallyexcreted, It maybe more advantageous to trya third generation cephalosporin that ishighly protein bound (e.g., ceftriaxone). Thisantibiotic is over 850/oprotein bound and at1-2 h post infusion has greater bileconcentration than in serum.’2 The bileconcentration should remain high due to themorphine sulfate this patient is receiving.

P: Recommend adding ceftriaxone 1 Gm q24hfor enterococcus coverage and maintainregimen of Primaxin@ for continuedpseudomonas coverage.

This patient was well known to the pharmacist,having undergone cisplatin-based chemotherapy forher adenocarcinoma of unknown origin. Althoughcomputed tomography (CT) images of the abdomendemonstrated resolution of her liver lesions, sequelaefrom her chemotherapy included anemia, electrolytewasting, and proteinuria. Aggressive replacement ofelectrolytes and albumin resulted in only a minimalincrease in this patient’s laboratory values.Furthermore, her low complete blood count,secondary to chemotherapy, made the diagnosis of“infection” extremely difficult.

The choice of imipenem/cilastatin was certainlyappropriate based on culture and sensitivity data, butbased on pharmacodynamic/pharmacokinetic data,the pharmacist believed that this drug’s normallyshort half- life, lack of protein binding and 70°/0-800/0excretion in the urine as unchanged drug would notbenefit the patient. On the other hand, ceftriaxone is85Y0-90% protein bound, has a longer half-life andnormally concentrates in the suspected site ofinfection. Both oncologists believed that therecommendation merited consideration, but the ~physician rejected the consult. After almost fourweeks of antibiotic therapy, with no realimprovement in the patient’s temperature andcontinued low WBC, seconda~ to chemotherapy, allantibiotic therapy was stopped. The patient wasdischarged to home care with the discharge diagnosisnoting an elevated temperature as “tumor fever, ” Thisillustrates the fact that your recommendations are notalways followed,’~ This case was categorized asMRP#2, i.e., improper drug selection,

Patient B: 84 y/o white male with persistent urinarytract infection (UTI) with urine culture positive forPseudomonas aeruginosa as an outpatient that wasresistant to ciprofloxacin. The patient was admittedfor iv, antibiotics (ABX).

Pharmacokinetics Consult:

o: Patient with UTI resistant to ciprofloxacin asoutpatient. On gentamicin 100 mg q 12h andceftazidime 1 Gm q8h. Blood levels on thisgentamicin dosage are peak= 10.2 mg/L andtrough = 6.0 mg/L (t).

A: These gentamicin levels indicate a half life of14 hours and a volume of distribution (V,) of17L, The patient’s creatinine clearance iscalculated to be 31 mL/min. Half life isappropriate for patient’s age and renaIfunction while V~ indicates patient is “dry”(dehydrated) which is verified by fluidinput/output (1/0) records.

With a half life of 14h, it is necessary towait about 24h to get a trough level less than2 mg/L and preferably less than 1.5 mg~.Tomorrow morning at 0800 trough calculates1,5 mg/L.

P: Consider random trough level tomorrowaround 0800. If level is appropriate and moregentamicin is required, then 80 mg q24h isestimated to yield a peak = 5,0 mg/L andtrough = 1.6 mg/L, If patient remains dryand/or serum creatinine remains at 1.7 mg/dLor increases, one may want to consider ( I)discontinuing gentamicin or (2) extendingdosing interval to q36h. Consider changingcefiazidime schedule to q24h seconda~ to adecrease in creatinine clearance.

Discussion: The consult was met with “mixed”acceptance, The ceftazidime schedule was changedas recommended. The gentamicin dose wasincreased above that recommended, but the schedulewas accepted, By the time the next gentamicin peakand trough levels were obtained, the patient wasbetter hydrated, but the serum levels were still high,This necessitated another “PharmacokineticsConsult,” along with a personal discussion with thephysician assistant caring for the patient. This casewas categorized as ~P #5, i.e., overdosage.

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Patient C:

o: Patient with aspiration pneumonia. Ongentamicin 100 mg q12h and ceftazidime 1Gm q8h. Gentamicin levels are peak= 5.2mg/mL and trough = 1.6 mg/mL. Serumcreatinine is now 1.1 mg/dL and trendingdown. WBC = 11,200/mm3 and trending upwhile temperature is still increased. Bloodculture results show: mixed aerobic andanaerobic gram positive cocci.

A: Gentamicin blood levels indicate a half life of5.8 hours and a V~ of 22.5 L. The half life isacceptable for a patient with a creatinineclearance of 40 m L/rein, V~ is greater thanpopulation average but is consistent with iv.fluid intake,

P: Recommend: (1) gentamicin 200 mg q24h toget increased peak levels for pneumonia.This dosage regimen should result in a peak= 8.9 mg/mL and trough= 0,7 mg/mL. (2)Add clindamycin 600 mg q6h for anaerobecoverage.

Discussion: In this case, the patient had been ongentamicin and ceftazidime for over 48 hours withouta significant change. The patient’s serum creatininewas trending down and was most likely secondary tothe iv. fluid therapy. On the other hand, thetemperature was still elevated and the patient’s WBCwas increasing, suggesting the antibiotics were not“covering” the infectious agent. As noted in thephysician’s progress notes: “aspiration pneumonia”was #l in the list of patient’s problems, but anaerobicbacteria are not covered by gentamicin and ceftazi-dime. Both recommendations were accepted. Thiscase was categorized as MRP #3, i.e., subtherapeuticdosage and MRP #1, i.e., untreated indication.

PHARMACEUTICAL CARE ANDDIAGNOSTIC IMAGING

The following six cases illustrate how

pharmaceutical care principles were, or might have

been, applied to help patients scheduled fordiagnostic imaging procedure~.

Case 1: h elderly diabetic with lower extremitycomplications is scheduled for a nuclear medicine

bone scan to aid in the diagnosis of osteomyelitis.The patient is injected with the radiopharmaceuticaland the three phase bone scan begun. It is thenrealized that the foot has already been amputated !

9Discussion: An appropriate patient interview or areview of patient specific information by the nuclearpharmacist would have revealed that the originalindication for the bone scan was no longer valid.This case is an example of Medication RelatedProblem #8, i.e., drug use without indication. TheMRPs as originally described by Hepler and Strandaddress problems associated with therapeuticpharmaceuticals, but this case is an example of howa simple “drug use review” by the pharmacist wouldhave avoided this diagnostic MRP.

Case 2: A 51 y/o white male is admitted with a chiefcomplaint of feeling “run down” in the past few days.Temperature was 101“F at home. The workingdiagnosis is pyelonephritis secondary to a defectiveurinary drainage device (broken, occluded stent).Other problems include diabetes with questionablecellulitis, osteomyelitis of left lower extremity andarthritis, He is started on vancomycin, ceftazidime,and gentami cin. After about 1 week, a ‘7Ga-citratescan is ordered to rule out infected kidney. The●choice of radiopharmaceutical was discussed with theID physician after the pharmacist wrote the followingnote:

o: Patient with pyelonephritis most likelysecondary to occluded stent. ‘i7Ga-citratescan ordered to “rule out infected kidney. ”

A: Ga-citrate study will take 48-72 hours tocomplete after patient is pretreated withlaxative.

P: Recommend 99mTcor ‘‘’[n leukocytes asalternative diagnostic radiopharmaceutical asuseful information can be obtained in s 24hours.

According to information in the patient’s chart, thepresent condition, pyelonephritis and non-functioning stent, were acute events, Thus, “gmTcor1]‘In leukocytes could have been prescribed anddiagnostic information obtained the same day orowithin a 24 hour period.’q After three days ofimaging with b7Ga-citrate the radiology report stated,

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“consistent with nephritis. ” Although the mostcommon cause of acute interstitial nephritis is drugrelated (antibiotics, diuretics, NSAIDS), the patient’sdrug history did not support this etiology. The most

likely cause was the non-functioning stent. ]s This

case was categorized as MRP #2, i.e., improper drug

selection.

Case 3: A 57 ylo white female is admitted with a

diagnosis of congestive heart failure (Cm) and

pulmonary edema. Her problem list includes lung

cancer (non oat cell) with lymphatic spread, skinmetastasis and pulmonary hypertension. Her pastmedical history includes S/P radiation therapy x 33doses, S/P Iobectomy, and completion ofchemotherapy about one month ago. The physicianprogress notes indicate that a strained right ventricleis resulting in the pulmonary hypertension. Althoughthe patient does not present with the “textbook” signsof pulmonary emboli (PE), such as tachypnea, chestpain and dyspnea, the oncologist wanted to rule outPE, ‘b Therefore, he ordered a nuclear medicineventilation/perfusion (V/Q) lung scan.

Discussion: The oncologist was contacted after thepharmacist notified the nuclear medicine staff thatthis patient may present a problem. Aggregatedalbumin is contraindicated in severe pulmonaryhypertension. ” Although this patient was notclassified m having “severe” pulmonary hypertension,this patient was unique in that she was S~ lobectomyand radiation therapy to the lung field. This patienthad fewer pulmona~ capillaries and the pharmacistreasoned that the therapeutic radiation may also havecaused radiation fibrosis in the contralateral lung andpossibly be a contributor to the right ventriclestrain. ]x Breed on the pharmacist’s recommendation,the oncologist canceled the V/Q lung scan anddischarged the patient to a hospice. This case is anexample of MRP #2, i.e., improper drug selection,and the pharmacist’s intervention prevented MRP #5,i.e,, overdose (potential for too many aggregatedalbumin particles) and MRP #6, i.e., adverse drugreaction (potential fatality).

Case 4: A 57 y/o black male presents with a chiefcomplaint of shortness of breath. Past medicalhistory includes CHF, cardiomyopathy, hypertensivecardiovascular disease and pulmonary hypertension.

furosemide 40 mg qd, digoxin 0.125 mg qd,amlodipine 10 mg qd, warfarin 10 mg qd, Iisinopril20 mg qd, KCI 20 mEq qd and amiodarone 200 mgqd.

Two days prior to admission, the patient develop-ed dyspnea on exertion, night sweats and nocturnaldyspnea. The patient denies chest pain ornon-compliance with his medications,

Physical exam reveals a moderately enlargedthyroid. Thyroid laboratory studies ( T TJ, 1Tl and1TSH) suggest a recent onset of hyperthyroidismpossibly induced by the antiarrhythmic amiodarone,

Discussion: Amiodarone is a class III antiarrhythmicavailable as 200 mg tablets and contains 37,2°/0iodine by weight with approximately 6 mg/day ofiodine released for each 200 mg ingested. ‘g Althoughmost patients on this drug remain euthyroid,thyrotoxicosis (2-30/o) or hypothyroidism maydevelop. In this case, the patient’s complaints,physical exam and thyroid lab studies suggest thethyrotoxic state. On review of his medication list,amiodarone was the only iodine-containing product,The drug or the iodine released has a direct effect onthe thyroid cell causing acute thyroiditis and aresultant release of thyroid hormones. ~()~’Amiodarone can interfere with thyroid function testsby inhibiting the peripheral conversion of thyroxine

(T.) to tri-iodothyronine (T,), Serum T, and reverseT~ may be increased while serum T~ may bedecreased. In this patient, both TJ and TJ wereincreased and thyroid stimulating hormone (TSH)decreased, all suggestive of hyperthyroidism,

This is a typical case of a patient on an iodine-containing drug in which the standard nuclearmedicine uptake and scan would be contraindicated.However, the nuclear tnedicine procedure wasselected to confirm the diagnosis ofamiodarone-induced thyrotoxicosis. The results ofthe lz~Isodium iodide uptake and scan yielded a 1‘Auptake and non-visualization of the thyroid bed, bothconsistent with exogenous iodide induced thyroiditisand thyrotoxicosis,

This is an example of MRP #6, i.e., adverse drugreaction, that was confirmed by the thyroid uptakeand scan.

Past surgical history includes placement of a pacemaker. His medications prior to admission include:

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Case 5: A 57 y/o white male presents to his family

physician with symptoms of diabetes, anemia, weight

loss and a skin rash on his extremities and lowerbody. His past medical and surgical history includea primary tumor of the pancreas surgically excisedabout 3.5 years ago. His current symptoms mimicthose from his original diagnosis

Neuroendocrine tumors, especially those ofislet-cell origin, are slow growing and 15 yearsurvival rates are typical in these patients. Theaverage age of onset is 50 years. Patients with tumorsthat secrete glucagon, which in turn, stimulatesgluconeogenesis by the liver, most often present withthe classical signs of diabetes mellitus. Frequently,weight loss, normochromic anemia,hypoaminoacidemia and hypolipidemia are present,but the most distinctive clinical feature in this patientwas the necrolytic migratory erythema (described bythis patient as a “rash”)

Treatment is by surgical excision of the tumor(s),but if the tumor is non-resectable or there aremetastatic lesions, a combination of streptozocin and5-fluorouracil are used. Octreotide acetate(Sandostatin@) can be used to suppress glucagonproduction with a concomitant improvement of thediabetes and rash.

The diagnosis of a glucagonoma was initially madebased on the patient’s elevated serumimmunoreactive glucagon. The oncologist wantedconfirmation plus evaluation of disease extension andthus ordered an ‘“In pentetreotide scan(Octreoscan@). Imaging results confirmed the initialdiagnosis with a solitary lesion at the tail of thepancreas and at least three metastatic sites in theliver.

This case presents a challenge for the pharmacistbecause many of these patients may be treated withoctreotide acetate (Sandostatin@) prior to thediagnostic imaging procedure, The current packageinsert does mention a potential drug interactionbetween the therapeutic agent and the diagnosticagent, but no detailed recommendations areprovided,22 The half life of octreotide acetate is60-110 minutes with a duration of action as long as6-12 hours.z3

lf pharmacokinetic knowledge is applied, thepharmacist would be inclined to recommend thetherapeutic agent be held for about ten half lives inorder that suficient receptor sites are available forIocalintion. But does the pharmacist use the half lifeor the duration of action as the basis for the

calculations? The pharmacist can be conservative andrecommend the therapeutic agent be held for 10-18

hours, or one day to be practical, or as long as 120hours or five days! Treatment with octreotide acetat

awould be a viable option in this patient because hepresented with the classical signs of diabetes mellitus.The most conservative recommendation should beoffered in this case so that the management of thediabetes would not be overly compromised.

Depending on what recommendation is made bythe pharmacist this case can be categorized as MRP#7, i.e., drug interaction, if the Sandostatin@ is notheld and it is later determined that a suboptimal studywas the result. If the recommendation is made to holdthe Sandostatin@ for five days then this would most1ikely be categorized as a ~P #1, i.e., untreatedindication (unless the diabetes can be successfullytreated via aggressive insulin therapy).

Case 6: A 50 y/o male is diagnosed withadenocarcinoma of the prostate with metastatic spreadto the lungs and bone. His past medical history isinsignificant except that his cancer was initiallytreated with thoracol umbar spinal irradiation for cordcompression followed by one cycle of chemotherapywith doxorubicin hydrochloride, His diseas

acontinued to spread and the chemotherapy wachanged to 5-fluorouracil and etoposide. His bonepain was initially managed with naproxen 500 mg poTID. Within days, morphine sulfate 30 mg po T~was added. About one month later his pain regimenwas: meperidine 25 mg i,m, q4-6h prn pain,promethazine 25 mg with each meperidine dose,morph ine sulfate 60 mg po T~, and naproxen 375mg po T~.

Six months later the patient is admitted to thehospital complaining of progressive pain. ~1demonstrated spinal cord involvement and he wastreated with high dose carboplatin anddexamethasone, The patient was discharged on thefollowing pain regimen: hydromorphone 3 mg iv,push every 3 hours for pain, fentanyl patch 50 mcg/hrevery 72 hours, oxycodone/acetanlinophen 2 tabletsq4h pm, ketorolac 10 mg po TLD,

Two months later the patient is admitted forevaluation of his pain I-egimen and a distendedabdomen secondary to obstipation caused by thenarcotic analgesics

Discussion: The patient’s disease was so advancedthat the pain management technique employed was

12

only partially successful and was causing severeadverse effects (obstipation), even though theconcurrent use of laxatives and stool softeners

● appeared appropriate, The pharmacist suggested “Srchloride as an adjunct to this patient’s painmanagement regimen. The patient succumbed to hisdisease before the therapeutic radiopharmaceuticalcould be administered.

This case is an example of multiple MRPs: MRP#2 (improper drug selection) -- 8gSrchloride should

r have been considered sooner; MRP #5 and #6(overdose, adverse drug reaction) - although it is an

P accepted standard of care to administer as muchanalgesics as required for the treatment of cancerpain, the exacerbation of narcotic-inducedconstipation (obstipation) made it clear that anotherpharmacologic approach should be considered.

These six cases illustrate the type of pharmaceutical

I care that can be performed for pati ents scheduled fordiagnostic imaging studies. Figure 1 is a form titledPharmaceutical Care Plan (PCP), that pharmacypractice faculty and students use in their patient careactivity at Mercer University. Figure 2 is a modifiedPharmaceutical Care Plan that is utilized in the careof patients scheduled for diagnostic imaging

●procedures. Many times during the drug review andpatient interview, the pharmacist will determine thatthere are no MRPs but the patient needs follow uplabs or needs to be referred to another health careprofessional. In this situation, MRP #9 is checked onour form, Many patients have their disease(s) wellcontrolled and only require a routine follow up, Inthis situation, MRP #10 is indicated on our form.

I REIMBURSEMENT FOR COGNITIVESERVICES

Significant literature has been published to assistthe pharmacist in establishing pharmaceutical careand receiving reimbursement for such services. ~4-s0Itis also noteworthy that pharmacists in other countriesare receiving payment for cognitive services. zs’zg

The most difftcult aspect of providingpharmaceutical care is simply getting started. Eightsteps have been outlined by Perri ‘f to facilitatepayment for patient care services that are completelyapplicable to nuclear pharmacists in the community

●or hospital setting.

Perri’s eight steps with suggested action plans areas follows:

13

1. Get Involved.Pharmacists need to get more clinicallyinvolved with the use of the drug productsthey dispense. Join your professionalsocieties and lobby for initiatives that supportpharmacist reimbursement. It is necessary forpharmacists to educate insurance companiesand benefit plan managers of the value ofpharmacist interventions.

2. Develop a plan.

Concentrate on a specific patient type, and/orimaging procedure, as outlined in Tables 2and 3, to begin your pharmaceutical careefforts, Appropriate patient medicationreviews are essential for all the nuclearmedicine procedures that includepharmacologic intervention’ Some typicalexamples are:

a. Hvpercalcemia of MaliznancvHypercalcemia occurs commonly inpatients with cancer and contributessignificantly to their morbidity andmortality. Lung, breast andhematologic cancers are mostcommonly associated with thisphenomena. Treatment ofhypercalcemia is multifactorialincluding hydration, bisphosphonates,calcitonin, corticosteroids,glucocorticoids, plicamycin, oralphosphates and gallium nitrate. Manyof these cancer patients are scheduledfor bone scans to evaluate the extentof their disease. Both etidronatedisodium (Didronel@) andpamidronate disodium (Aredia@)have exceptionally long “bone” halflives and it is not practical to expectthe patient to be off this therapy formore than a week before the bonescan, Health mre providers should beinformed the patient is taking either ofthese drugs and a suboptimal bonescan might be possible.

a, Cardiac stress studie~Adenosine (Adenocard@) anddipyridamole (Persantine@) are two

—

=

—

i

-

—

—

=

—

—

—

—

14

15

potent coronary vasodilators used as

adjuncts in myocardial imaging. Oftentimes, these procedures are performedin the morning. Appropriate patientcounseling needs to be performed bythe pharmacist so the patient isinformed that beverages such ascoffee, tea and many soft drinks willinterfere with the outcome of thestudy. Patients prescribed theophyllineor those using common OTCanalgesics containing caffeine alsoneed to be informed about the possibleinterference and should be offeredalternative medication or dosingschedules, ~z

3. Getmore information.A practical problem faced by all pharmacistsattempting to offer pharmaceutical careservices is the availability of relevant clinicalinformation. This situation is particularlycritical of those practicing in CNPS. It will benecessary to establish a professional rapportwith client institutions, Start small - select oneclient institution and begin a mini-externship innuclear medicine. Interview the outpatients,take a medication history and review thepatients’ chart and medication administrationrecord (MAR) for inpatients. Participate in thefilm reading sessions with the radiologist/nuclear medicine physician and as you becomecomfortable with the nuclear medicine staffyou can begin to offer professional advice. Ifthere are pharmacist clinicians at the institutionbegin making rounds with them as a means ofdeveloping a professional rapport. Educatethem on the MRPs as they relate to nuclearmedicine procedures.

4. Choose a starting point.Ask to be consulted in select cases, such asoutpatient cardiac stress patients or bone scansin oncolob~ patients and request that thepharmacist clinicians support you with objec-tive data from the patient’s medical record, Ifyou offer services to a client institution whichis covered by an annual contract, includepharmaceutical care services in the contract,When a positive contribution is made andaccepted, file a claim with the patient’sinsurance company or benefit plan manager,

5. Provide documentation of service.Document all your interventions -- those thatare accepted and those that are rejected, Usethe PCP forms included with this article,Your documentation is vital in supportin Byour claim for payment of cognitive services.

6, Identify potential payers.

Check with the clinician pharmacists in yourcommunity who are being reimbursed forcognitive services; what did they do to getpaid? Do the same thing! Find out from planbenefit managers and insurance companies inyour state what you need to have in place inorder to be reimbursed.

Some states or insurance companies mayrequire the pharmacist have a providernumber wh iIe others wi II accept a letter fromthe patient’s physician authorizing thepharmacist to review the patient’s drugtherapy and other medical record information(“medical necessity”), Whatever system is

being utilized by the pharmacists in yourcommunity is the one to adopt, The article byConstantine and Scott ~’is particularly helpfuin describing the strategies used bbpharmacists who are being reimbursed forcognitive services.

7. Establish professional fees.

This is one of the most difficult aspects ofreimbursement that pharmacists face oncethey begin offering cognitive services. First,check what is happening in your community,How much are community pharmacists,hospital pharmacists and nursing homeconsultant pharmacists charging? Check withyour state and national professional societiesto see what the current social or politicaltrends are. Physicians and other health careprofessionals have been charging for“non-product” Semites for such a long time it

is second nature to them, K you start small, assuggested, you can determine a reasonable feethat can be adapted to other situations as yOLI

expand your pharmaceutical care services.

8, Submit clnims for service.

Once these steps are initiated, the pharmacistmust submit a claim form to the patient’s

16

●

●

●

insurance company for reimbursement. It is

mandatory that the pharmacist complete these forms

accurately to facilitate payment. Two forms are

available, the “Pharmacist Care Claim Form”

(PCCF), from the National Community Pharmacists

Association (NCPA) [available from Meal-Pass, P.O.

Box 367, Dayton, OH 45459, (800)438-8884, FAX

(51 3) 438-8361] (Figure 3) and the universal claimform used for Medicare and Medicaid patients,“Health Insurance Claim Form”, Form HCFA- 1500,(800) 477-7374 (Figure 4). Both forms have beenused successfully by pharmacists seekingreimbursement for cognitive services. These formscontain U the vital information that must becompleted for successful reimbursement. As with allforms, there are “tricks,” and one is advised todiscuss the proper completion of the forms with localinsurance companies or practitioners prior tosubmission. Two references are avai Iable that willexplain the proper procedures, Common ProceduralTerminology (CPT) codes, and other informationnecessary to submit a successful claim.Js’q4Thesereferences are essential because it is easier tocomplete a claim form correctly prior to submission,than to correct one once it has been submitted andrejected.

Figure 5 is a completed “Pharnlaceutical Care forDiagnostic Imaging” form for patient Case 3. Notethat the requested V/Q Scan is listed in the column“Drug/Dose/Schedule” and categorized as MRP #2and 67 Improper llrug Selection and Adverse Drt[g

Reaction. On the bottom of the form, in thePharmacy Notes section, the action taken on behalfof the patient is documented. Note that therecommendation was categorized as being followedand the outcome achieved. The form illustrated inFigure 2 can be faxed or e-mailed to clientinstitutions and completed by the nuclear medicinetechnologist or the pharmacist at the institutionperforming patient care services.

Figure 6 illustrates how the Pharmacist ClaimForm is completed for the patient in Case 3, UnderColumn I, “Reason for Services,” the last entry(0/her) is checked for the package insertcontraindication of perfusion imaging and pulmonaryhypertension, Although fewer aggregated albuminparticles might have been suggested in this case, it isof particular concern that the patient had a lobectom yand 33 courses of radiation therapy. Thus, with only

one lung and probably some pulmona~ scaringsecondary to the radiation therapy, it is virtuallyimpossible to determine the safe number of particlesto use.

In Column ~ under Professional Services, PatientCare, Prescriber Consulted is checked because theoncologist was contacted. The “Recommendations”in Column III included canceling the V/Q scan alongwith not dispensing the radiopharmaceuticals.

Column TV documents the “Results of Services”and notes that the prescription was not filled, therecommendation was accepted and the patient wasdischarged to hospice care. This consult potentiallyprevented a fatal drug event, therefore it was classifiedas Level 5 (highest) in Column V, “Level ofServices.” Rupp discusses the five levels of care andLevel 5 included the following components:24

1. “~heservice provided was comprehensive.

2, The service involves extensive diagnosis ortreatment options, exceptional amount ofcomplexity of data considered and very highrisk,

3, Counseling or coordination of care dominatesthe service and it required more than one hourof the pharmacist’s time.

The consult is written in SOAP format in the“Discussion” section of the form to support thereimbursement claim.

CONCLUSION

Academic and community nuclear pharmacistscan become more clinically involved by becomingproactive and preventing medieation-related problemsthat may interfere with diagnostic imaging

procedures.The examples illustrated in this paper give the

pharmacistphysicians,

a proven method to communicate witheffect change and seek reimbursement.

17

—

FIGURE 3 PHARMACISTCARE CLAIMFORM

.

Address

Clfy

SUBMITPhone

“to ●REFERENCE

NUMBER

<!, -ale Z!p

St. Scclal Securty, Sub!jcroer c V. ~D~[eof Serv,ce

M=, I

~Emp:oyer i D

CERTIFICATION STATEMENT

I cerfify that the pa!ient information entered on this form

correct,the patientnamed is eliglbie for the benefits,athe patient has received the pharmacist care/setvlcrendered.I authorizereleaseof informationIn thisrecordhealthcare providers,institutions.and/orpayersas may

Employer

Grouo No ! Plan No,

I I necessa~ to facilitate care and/or Drocess Davment—

Self

I Blrrhdate

,,pharmacist care rendered.Sex

MF1

D Other

-

❑ Soouse ~

If Yes. Where?

Relat!onshlpaf Pattentto Subscriber o

Full-T!me Student U Yes ~ No

Signature Date

Drug Product Selection01 ❑ DrugNeededButNot

Pr~scrlb*d02 U Prescribed~ru~Not

Needed

03 ❑ Dunllcation

40 ❑ Contact Health Care

Prov!der

41 H Contact Thtrd-Party Payer

60 L Add Drug

61 G Dtscontlnue Drug

62 ~ DO Not Dispense Drug

63 0 Charlge Drug

64 ~ Change Dose

65 ❑ Change Dosage Form

66 ~ Change Route

57 ~ Change Schedule/Duratton

68 ~ Referral

69 ❑ Self-Care

70 0 Continue Without Change

98 ~ Other (Specify)

80 E Drug Added

81 ❑ Drug D!scontmued

@2 ~ Crug Not D\spensed

42 ❑ Counsel Patient

43 ~ Counsel Patient’s

Careglver

83 ❑ Drug Changed

84 ❑ Dose Changed

85 ❑ Dosage Form Changed

86 ❑ Route Changed

87D Schedule/Durahon Changed

44 Q Demonstration

45 ~ Develop Compliance Ald

46 ~ Education

47 ❑ Monitor Drug Therapy

48 n Refer

49 ❑ Consult on Self-Care

107 n cost88 u PatlenI Accepted Retemal

89 ❑ Patient Accepted Self-CareIRegimenM ❑ Des%

G9 ❑ Schedule/Duration

90 D Recommendation NOT Accepts

97 ❑ Other (Specify) 99 Q Other (Spac!fy)

d 10U Route

11 ❑ Dosage Form

Contralndicationllnteraction+~ ❑ Age

13 ❑ Disease or Condition

14 U Drug

15~Fti

16 ❑ Laborato~

17 ❑ Pregnancy/Nursing

,, ...

Adverse Effrsct18 ❑ Additive Effects

19 ❑ Allergy

20 ❑ Toxtcity

Requati for Information21 ❑ Patient22 D Patierd’gCareglver23 ❑ HeatthCar@Provider24 D Third-PartyPayar

Patient Product Mlause25 ❑ Underuse

26 Q Overuse

27 ❑ Abuse

28 ❑ Not Filled or Refilled

39 ❑ Stored Inappropriately

30 ❑ Prescription Clarification

96 U Other (Speedy)

. . . 0,*W

code

,,, ,+$Fee Code~

~nd~......l... ...i. .1 I 1.! ‘. 1..1.-.1--JI 1 I .1,F:e TOTAL FEE

I

I herebv certlfv that the DhafmaClat care rendered as lnd!cated has Deen com~lNAME

\ and the feeS $ubm!tted are the actual fees I have charqed and >ttnd to COIIiC

1ADDRESS

PHONE

NABP NO.

/ those sew,ce$.

Signature of Pharm-ird

1-

Date Licen~ No.

5SN; TIN

,993 NARD WMITE - PAYER YELLOW . PATIENT PINK - PHARMACY/OTHER

18

PLEASEDO NOT

A

STAPLEcg

IN THISAREA FIGURE 4

Krdv~

MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHEM la lNSuREo’s I D NUMBER ,FOR PROGRAM IN ITEM 1) ‘~

~IMPOIC.rEU~ M.OICJ, # ~ 5oonsors SSN) m (VA Fle ~ ~H~;~o~fl ~BL&~~ (ID)——

PATIENT S NAME lLast Name F’:st VAm* Mldd!e I.,!,all 3 PATIENTS BIRTH DATE SEX 4 INSURED’S NAME (Last Name, F!rstName Mlddl~ Inltlall

MM IDDIYY

1 I M F

‘A TIENTS ADCRES$ (ho Slreel) 6 PATIENT RELATIONSHIP TO INSURED 7 INSURED’S ADDRESS (No,, Street)

““ m’””’”m’””m 0“’”n—.:Iv STATE 8 PATlENT STATUS

I“’g’”n ““””n “’”’n

:IP CGDE \ TELEPHONE tIncludeArea Cole) ~i TELEPHONE (INCLUDE AREA CODE)

1( ) Employtim $= ~~q. ~ () IEg

OTYER INSURED’S NAME 1Last Name, FIrsI Name Middle In,t,al) 10 IS PATIENTS CONDITION REIATED TO i INSUREDS POLICY GROUP OR FECA NuMBER ~

I OTHER INSURED S POLICy OR GROUp NuMBER a EMPLOYMENT (CURRENT OR PREVIOUS)I

UYES ONO

I INSURANCE PLAN NAME OR PROGRAM NAME I od RESERVED FOR LOCAL USE

READ BACK OF FORM BEFORE COMPLETING& SIGNING THIS FORM.12, PATIENTS OR AUTHORIZED PERSONS SIGNATURE I aulhonze the release of any m6di-f or other lnfo~ati~

ngcessary to process this cialm. I also isquest payment Of g~ernment benefits edher tO mY$eti Or tO the Pam who a~~sassignment below,

SIGNED — DATE —

14 DATE OF CURRENT

I I 4

ILLNESS (First symptom)ORMM

15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESSDD I YY INJURY (ACC,denl)OR GIVE FIRST DATE MM IDD IVY

PREGNANCY (LMP) I I

7 NAME OF REFERRING PHYSICIAN OR OTHER SOURcE 17a. I D. NUMBER OF REFERRING PHYSICIAN

119 RESERVEO FOR LOCAL uSE

21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1,23 OR 4 TO ITEM Z4E By LINE)

i

I L,_ 3.L. —

2 L.— 4L, —

24 A B c D E

DATE(S) OF SERVICE Place T:~ PRoCEDURES, SERVICES, OR SUPPLIES

From To 01 (ExplaIo Unusual Cimmstances) DIA:ON:ESIS

MM DO yY MM CID yy Sewlce Sewlce CPT/HCPCS I MODIFIER1

t I I I

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~25 FEDERAL TAX I D NuMBER SSM EIN

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INCLUDING DEGREES OR CREDENTIALS

)

(1certIV Ihal [he $tatnmenlsOQthe r~vers~apply to thisb,lland are made a pad Inereof )

[51GNCU DATE

(APPROVED BY AMA COUNCIL ON MEDICAL SERvlcE ~1

C1502

II I

26 PATIENTS ACCOUNT NO 27 ACCEPT ASSIGNMENT?(For govl, cla,ms, SM back)

YES ~ NO

32 NAME AND AODRESS OF FACILITY WHERE SERVICES WEREflENDERED (If other lban fiOmeor offIc#)

1) PLEASEP~lNTORTYPE

INSURANCE PLAN NAME OR PROGRAM NAMEG

FF

IS THERE ANOTHER tfEALTti BENEFIT PLAN7~

U YES m NO Wy- rOmmto anc c0mph3feItem 9 ad.

3. INSUREDS OR AUTt60RlZED PERSON’S SIGNATURE I authorizepayment of mti=sl bneftis 10 the undersigned physlclan or supplier forsewEm *wnbad blow

ISIGNED

6. DATES ~~TIE~ IJJ ;;wORK IN CURRENT ~cupATloNMM IDQIYY

FROM , , TOI, ,,8 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

MM IDDIW MM IDDIYYFROM I I

TO I

‘o. OUTSIDE LAB? $ CHARGES

DYES ONO I

Q. ~~flCAID RESUBMISSIONORIGINAL REF MO.

II

!3. PRIOR AUTHORIZATION NUMBER

F G n I J Kz—

DAYS EPSDT$ CHARGES OR Family EMG COB

RESERVED FOR s

uNITS Plan LOCAL USE.%

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H. ;HY%::’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE

PIN# GRP#

FORMHCFA-i 5~ (12.W)

FORM OWCP.15W ‘ORM RRB-15C0

APPROVED OMB-09387~h,nHealth Record SyslPms (d!v of prOfeSSlOna, Ffllng sY~tems Inc )TO Order Call 1-800-477.7374, In Atlanta 770/396-4994 19

—

—

.

—

—

FIGURE 6 PHARMACIST CARE CLAIM FORMFORM #ND120S,+E:>6?EZ ‘=CW JR,,-.>,?#.w

Grne i Tekw I SLIBMIT TO

city

~~hdate Sex Social Secur}ty/Subscriber 1. D. No

Mm F

Employer

Group No, Plan No

State Zip IPATIENT AUTHOFI l~TION

IDaIe of Service I I hereby authorize release of Information to health care

Employer 1. D.

providers, institutions, antior payers that may pertain to

~ my Illness and/or treatment recetved. I certify !hat the

!Information I have reported with regard to my Insurance

coverage is correct, and I have received the pharmacistI care/services rendered.I

Name I Sirfhdate

IRelatlonsh,p of Pafient to Subscriber ‘:S elf ,: SUouse ~Chtld -~bther I

AWIMSWATIW_Call Help Oesk CH

_Drug NM AvaklaMe NA

—Miaama lnformatioWCltitication MS

_New &tient P~ssing

_Non-Formulaq DN

_PayerP~ Ousaticm

_Pre~w ~oify

_Prddwct Sefecfion ~rtunify

f3Q~m

_Ex-w Dur’sIh

_ExM& Wan*

_Hiih ~

_lnauMcisM Durati

_lnsu*knt Quantity

_Low k

_ovwuse

—~a -* Form_S@md __urt-

DRw c~__.Aa Tmi~

_~Age -tin

_DwAUe~

_Dw~ (-1)

_*D_ (ln*red)

_Dr!.ig-Drug lntera-

_Dru@G*

_Drug lncom~tt~i ‘

_DrWPregnancy

_latrogenic Conditfon

_lngredfenf Duplicatim

_LactatiiNutirtg Precati_Prior A*rae D~ Ftmti_~erapeutic DupficatW

DIS~SE MANAGEMENT

_Additionssi Drug Needed

_A~ Drug Raacfion

_Apparent Drug Miauaa

_Heaffh Provider Ffeferrsd

_bboretwry Test Needed

_New DisstiD_

_Pstient Complaint tSymptorn

_F’atiSfrt QuaaWCancern

_Preecriber Conaultatti

_Suboptimal Q@l*fion

_Unrr-=ry Drug

PRECAUTIONARY

_AlcoM Pr-ufion

_Drug-Focd Irsterachon

_Drug-Lab Mnfikt

_Si* EM

_Tobacco Lfae Precautti

zzOMar (* below)

Contraindication

NP

NF

TP

AN

Ps

Mx

E%

HO

Mh

Ns

LD

ER

SF

S.R

LR

AT

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ADMINISTRATIVE

_Formu!ary Enforcement FE

_Generlc Pduct Sel- GP

_L1toratum SeatiRmtw Sw_Pabent MsdiwIon Histoy PH

_Payer/Prm~r Consuited TC

__Therapeutk Prcduct Interchange TH

PATIENT CARE

_Coordinafion Of Care cc_Medication Review MR

_Pafient Aaaeasrmmt AS

_Pstient Constied Po_Patient Edu~tian#nstructjon PE

_Patient Monitoring PM

_Perform -rato~ T* w

Pharmacist Cof!sultad Other Wrce RO

~Preacr,bsr Consulted MO

_Recornmended laboratory Teat FeT

_Self-Care Conauffatlon Sc_Other (wifv below) 97

Level 1 (Lowest) = 11

Level 2 = 12

Level 3 =13

Level 4 =14

Level 5 (Highest) = 15

\ sexl~Fi Patient Signature

!

Ill.RECOMMENDATfONSDISPENSED

._Overrlde - Con fllct Invalid

__,..Overrlde . Con fltct Not Slgn,flcant

_Change Dose

_Change D{recttons

_Change Drug

_Change Quantlw

_Revlew Prescrlptlon w/Prescriber

__.. Substitute a Generic

_Change to OTC Product

XA

XB

xcXD

XE

XF

XG

XH

XJ

NOT DISPENSED

XADO Not Dispense Drug YA

PATIENT CARE

_Perform Patient Care Service 2,4

_Dlscontinue Drug Zc

_Change Regimen ZD

.._,-. Change Therapy ZE

_Change Therapy to More Effecbve ZF

and More Costly Drug

_Continue Without Change ZG

_Extenslve, Report WIII Follow ZH

Refer Patient to Another Professional ~

~Other (spsc!ty below) 98

Cancel V/Q Scan

Dale

DISPENSED

_FIlisd As IS False Positive 1A

-._ Flllea Prescription As Is lB

_Ftlled, Wdh Different Dose lC_Filled, With D, fferent Directions I D

_Filled, With Ditiera.nt Drug iE

_Filled, WI!h Diffareti Quantify i F

_. Filled, With Prescriber Approval 1G

_Brand-lo-Generrc Chartge IH

_Rx.to-OTC Change lJ

NOT DISPENSED

‘3_ PrescrlpUon Not FIllad 2A

_Not ~illecf, Dlractiona Clarified 2B

PATfENT CARE

X&Racciwmendat,on Ameptsd 3A

__ Recommendation W Ameptad 3B

_Discontinued Drug 3C

_Regimen Changed 3D

_Therapy Changed 3E

_Therapy Ghsnged 3F

Cost Imrease Acknowledged

._Drug Therapy Unchanged G

_Follow-Up Report 31-t

_Patient Referral m

_Orher (apacdy blow) 99

I ,1

o:

A:

P:

L~“’p-

Patient with Lung CA and multipleTOTAL

).FEE _...__, .-.-_... . . .mets. S/P lobectomy and XRT x 33 dd~es. Now wltnpulmonary HTN, probably secondary to right ventricular.strain. ?? etiology of pulm HTN, R\O PE.

99mTc Aggregated Albumin contraindicated in PulmonaryHTN due to decreased diameter of pulmonary capillaries.Probably exacerbated in this case due to XRT andlobectomy.

Cancel V/Q Scan.

‘“- ~ Cardiovascular care ~ Diabetes care ❑ Orthotlcs’prosthetics care

~~h. j ~Ostomy,, ncont,nevcewoundcare ~~Resp#ratory care nOthe,-NUCl_~.a..r. ~azrnacY Car[<

TELEPHONE I hereby certify that the pharmacist care rendered as indicated has been completedand the fees submitted are the actual fees I have charaed and intend to collect forthose servjces.

.

Stgnafure of Phamac8st

b

ssN/’riN I Date Pharmacist ~.D

WHITE PAYER YELLOW - PATIENT PINK - PHARMACY/OTHER

21 ‘

Rcfcrcnccs

1.

2.

3.

4.

5,

6.

7.

8,

9,

10.

11,

12.

13.

14.

Kavula MP, Eamctt CW. Jobsatisfaction, positivepractice aspects, work activities and personalitycharacteristics of nuclear pharmacists, J Nuc MedTech 1990; 18:270-74,

Glaxo Inc. Glaxo pathway evaluation program forpharmacy professionals, Career Option ProfilesRadio/Nuclear Pharmacists. 2nd ed. ResearchTriangle, NC. 1993:417-33.

Rhodes BA, Hladik III WF3,Norenberg JP, Clinicalradiophannacy: principles and practices, Semin NuclMed 1996; 26:77-84,

K~vulaMP. Case reports: observations, assessmentsand plans - SOAPing a consult. Proceedings of the142ndAnnualMeetingof the American PharmaceuticalAssociation; 1995 March; Orlando, Florida,

Gregorio N, Hladik WB, Kavula ~, ‘~henuclearpharmacist as a consultant and drug informationspecialist. J Phann Pratt 1989; 2:284-86,

IHeplcr CD, Strand LM. Opportunities andresponsibilities in pharmaceutical care. Am J 1lospPharm 1990; 47:533-543,

Shaw SM. Diagnostic imaging and pharmaceuticalcare. Am J Pharm Ed 1994 (summer); 58:190-193.

I-Iammes RJ, Babich JW. Positron emissiontomography:Clinical applications and pharmaceuticalcare, J Pharm Practice 1994; 7:124-139.

hart LL, Gourley Dr, Hcrfmdal ET (eds). Workbookfor clinical parmacy and therapeutics. Williams andWilkins, Baltilnore, MD. 1988, pp. 1-4.

Developingthe pharmacotherapeutic plan and wl-itinga FARM note. PHA 41 1/412/414, VirginiaCommonwealth University 1994-95,

Kerr RA, Gold ML. Systematic approach toidentifying and solving medication therapy problems(handout), Department of Pharmacy Practice and

Science, University of Maryland, Baltimore,

Strand LM, Cipolle RJ, Morley PC. Pharmaceuticalcare: An introduction. The IJpjohn Company 1992,Kalamazoo, MI.

Straus HW. ‘~he al~ful dodger, J Nuc Med 1992;33:3A

Datz FL, Use of ‘9’”Tchexamethylpropylcncamineoxime-labeledleukocytesfor detecting infection, WestJ Mcd 1992; 157:60-63.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30,

31.

SteinJII, Internal medicine: diagnosis and therapy, 3rdcd 153. Stanford (CT): Appleton & Lange, 1993.

Ibid, pp. 106- I 10.

Medi-PhVsics, Inc. MPI MAA Kit package inscti.●ArlinktionHeights, IL: 1990 October

Feldmcicr JJ, Weiss GR (eds). Radiation oncology inclinical oncoloW. Stanford (C’~): Appleton & Lange,1993. P. 87.

Facts and Comparison, pp. 148n-1480, 1996.

Lacy C, Armstrong LL, Ingrim NB, Lance LL. Druginformation handbook, 4th cd. Washington (DC):American l’harmaccutical A.~iation; 1996. p. 64-66.

Dipiro J1’, Talbell RL, Yee GC, ct al,Phamlacoiherapy, 3rd ed, Stanford (CT): Appleton&I.ange, 1997, p. 1529.

MallinckrodtMedical.Octreoscan(@Package Insert. St.Louis, MO: 1996.

Lacy C, et al, Ibid.

Constantine LM,cognitive services:Sept; NS35: 15-19.

p. 872-S73.

Scott S. WinningWhat works. Amcr

payment forPharm 1995

0l’erri 111M. Eight steps toward payment for cognitiveservices, Amcr Phalm 1995 Sept; NS35 :20-24.

Rupp MT. Standardizing documentation for tilingpharmaceutical ctil-cclaims, Arner Phtirrn 1995 Sept,NS35:26-30.

Fostc]- SL, Smith E13, Seybold MR. Advancedcounseling techniques: Integrating assessment andintervention, Arntr Phatm 1995 Ott; NS35 :40-48, ‘

Poirier S, Garicpy Y Compensation in Canada forresolving dl-ug-reltitudproblems. Amer Phtirm 1996Feb; NS36: I 17-122,,

Akaho,Eilchi,Armstrong EP, Fujii M. l’ha]maceuticalGal-c inititltivcs in Japan, Amer Pharrn 1996 Feb;NS36:123-127.

Stovtir KA Moving phalrnacisls toward providingpharmaceutical care, Amcr Phann 1966 Feb;NS36:137-140.

Park HM, Duncan K. Nonrtidiuactivc phalmoceuiicalsin nuc]car medicine, J Nucl Med Tccll 1994;22:240-249,

0

22

32.

●33.

34.

Greenstcin LB, I latch JL, Shel~in TP. Ongoingcontinuous quality improvement strategy usingpharmacologic stress with intravenous dipyridamoleand pharmacist intervention to reduce suboptimalexercise myocardial perfusion scans. J Pharm Pratt1994; 3:89-92.

Academy of phmacy owners manual for billing forcognitive services, 4th cd. Sacramento (CA).California Pharmacists Association; 1997 June.

Coding and reimbursement .guidc for pharmacists,ICD-9~CM, CPT, 14CPCS Level 11,NCPDP codes,definition, md guidelines. Reston (VA): St. AnthonyPublishing Inc: 1997.

QUESTIONS

1,

2.

3.

4.

●

The patient’s problem list can include:

patient concerns:. health professional concernsc, abnormal lab valuesd. all of the above

Information included in the subjective portionof the SOAP Note is most ofien obtained by:

a. reading physician progress notesb. reading typed consultationsc, interviewing the patientd. reading the nurses notes

Information included in the subjective portionof the SOAP N is:

a. measurableb. objectively verifiablec. a & b aboved not memurable or objectively

verifiable

Information in the Qbjective portion of theSOAP Note includes:

a. past medical history, medicationadministration record

b. vital signs, lab results, drug levelsc. imaging results, consultant notesd. discharge repo]l, patient’s physical

appearance

5, The information in the Qbjective portion of theSOAP Note is:

measurable;. objectively verifiablec. a & b aboved. not measurable or objectively verifiable

6. The pharmacist must be familiar with theinformation

in the patient’s record in order to determine ifthere are any medication related problems

subjective and objective:. detailed md superfluousc. descriptive and anecdotald. questionable and unverified

7, A pharmacist is going to write a therapeuticrecommendation in the patient’s medical record.The justification for the recommendation willbe included in the section of theSOAP Note.

a. Subjective

b. Objectivec. Assessmentd, Plan

8. JB is a 54 y/o white male who complains ofchest pain at his most recent visit to his familyphysician, He is otherwise healthy and in noacute distress. His past medical histoV includesa broken leg at 16 and mild arthritis, while hissocial history includes 3-6 cups of coffee a dayand 1-2 caffeine containing soft drinks a day.He takes no prescription medication but takesenteric coated aspirin as needed for his arthriticpain. His family physicirm schedules him for aDipyridamole (Persantine@) - Thallium StressTest.

This patient’s problem list will include:

a, recent onset of chest pain, mild arthritis,significant caffeine intake

b. recent onset of chest pain, mild arthritisc. recent onset of chest paind. chest pain, arthritis, caffeine intake,

taking enteric coated aspirin

23

9. The nuclear pharmacist assesses patient JB’sinformation and determines that themay cause a problem with the nuclearmedicine procedure.

arthritis;. history of a broken legc. mpirind. caffeine

10. In his SOAP NOTE the nuclear pharmacistwill recommend:

treat arthritis with NSAID:. discontinue mpirin once NSATD

startedc. discontinue ctieine ingestion 24 hours

prior to dipyridamole-thallium studyd. discontinue ctieine ingestion 72 hours

prior to dipyridamole-thallium study

11. CB is a 57 y/o white female who has beentreated for the past 5 years for hypertension,hypothyroidism and arthritis. Her homemedications are: captopril 25 mg BLD,thyroxine (Synthroid@) 0.125 mg qd, andenteric coated aspirin 1 or 2 prn pain. At hermost recent physicim’s visit she complains ofchest tightness with occmional pain, Herphysician schedules a Dipyridamole(Persantine@) - Thallium Perfusion Scan. Themorning of her study she needs to take someenteric coated aspirin while waiting in nuclearmedicine. She forgot her EC aspirin at home,but the Nuclear Medicine receptionist offersher some Anacin@. The nuclear medicinetechnologist calls for your advice, which is,

a. don’t take the Anacin@, it containsctieine and will interfere with thestudy,

b. if the patient has ingested theAnacin@, reschedule for tomorrow

c. advise patient to take no OTCanalgesics containing caffeine

d, all of the above

12. A 60 y/o black male with mild renovascularhypertension and corona~ artery disease is onthe following medications: Capozide@ 25-25qd, enteric coated aspirin 81 mg qd andnifedipine (long acting) 30 mg qd. At his last

office visit the patient’s serum creatinine andBUN are incremed and his physician isconcerned about renal failure secondary toincreased arterial stenosis. The patient ‘scheduled for a captopril renal scan and you a@requested to review the patient’s medication andto make recommendations as needed. Yourassessments and plan includes:

a. Continue nifedipine and EC ASA asordered, stop Capozide@ 48.0 hoursprior to study,

b. Current drug therapy needs no changes,proceed with nuclear medicine study,

c. Continue nifedipine and EC ASA asordered, do not take Capozide@ themorning of nuclear medicine study.

d. Continue nifedipine and EC ASA asordered, stop Capozide@ 24,0 hoursprior to study,

13. A 25 y/o white male is recovering from a gunshot wound to the abdomen, He has been fedvia hyperalimentation fluids since surgery fourweeks ago, He now complains of right upperquadrant pain and his surgeon wants to performa nuclear medicine hepatobiliary study. ●You review this case and offer the followingassessment:

a, Anticipate no problems with nuclearstudy, proceed as scheduled.

b. Nutritional therapy for 4 weeks mayresult in non visualization of gallbladder, reschedule nuclear procedureafter patient eating by mouth for oneweek.

c, Nutritional therapy for 4 weeks mayresult in non visualization of gallbladder, consider using cholecystokinin(sincalide) as pharmacologic adjunct,

d. Nutritional therapy for 4 weeks may

result in non visualization of gallbladder, consider using meperidine HC1as pharmacologic adjunct.

24

14, The nuclear medicine ptocedure is performedusing cholecystokinin as an adjunct. Therecommended dose of cholecystokinin

o (sincalide) is 0,02 mg/kg. The patient weighs150 lbs. and is administered 2.0 mg of thedrug. You review this case and determine thatthis is a Medication Related Problem # —$

2, improper drug selection:. 3, subtherapeutic dosage

5, overdosage;. 8, drug use without indication

15. Oncology patients who have either prim~ ormetmtatic bone involvement may experiencehypercalcemia, Which of the following drugsused to treat the hypercalcemia may interferewith the nuclear medicine bone scan?

dexamethasone:: hydrocortisonec. parnidronated. all of the above

6. A 55 y/o white male with diabetes mellitus isadmitted with cellulitis and possibleosteomyelitis, He is an insulin dependentdiabetic (for 20 years). This is his firstadmission with a “non-healing” sore that is aresult of a mountain bike accidentapproximately 1.5 weeks ago. At the time ofthe accident, he did not seek medical attentionand his self care included washing the affectedarea and application of OTC antibioticointment twice a day. His diabetes is wellcontrolled as indicated by a glycosylatedhemoglobin of 6.2V0 and the only laboratorytest not within normal limits is his white bloodcell count which is slightly elevated at12,500/mm3. You are consulted on this caseregarding the appropriate radiopharmaceuticalto rule out osteomyelitis. Based on the aboveobjective data, you recommend:

a. b7Ga-citrate

b, ‘]‘In leukocytes

c. 99mTcleukocytesd< ‘gmTc~P three phase bone scarI

17. Your recommendation in the prior question wasbased on the assessment which included:

patient problem is acute:. W13C only mildly elevatedc. diabetes well controlledd. all of the above

18. A 75 ylo diabetic patient is admitted withcellulitis and osteomyelitis on his left lowerextremity which is confirmed by the ‘9”Tc MDPthree phase bone scan. His WBC are markedlyelevated at 20,000/mm3 and his temperaturehas ranged from 99°- 102”F. He has been onbroad coverage antibiotic therapy but his caregivers are considering amputating the limb. Hehas mmpromised circulation (as per Doppler) inhis left lower extremity and you are consultedby the surgeon regarding what imagingradiopharmaceutical to use to determine theextent of the bone infection. Upon assessing theabove case your recommendation is:

‘7Ga-citrate:: ‘‘’in leukocytesc. ‘gmTcleukocytesd. any of the above

19. In the previous case your patient problem listincluded: 75 y/o diabetic with cellulitis andosteomyelitis and your assessment andrecommendation was based on the followingobjective data:

a. compromised circulationb. elevated temperaturec. elevated WCd, all of the above

20. In the previous case, which of the following

objective information had the least importance

in influencing your recommendation:

a, broad antibiotic coverage

b. compromised circulation

c. elevated temperature

d. elevated WBC

25

21.

22.

23.

24,

25

Which of the following classes of nuclearmedicine procedures can be utilized as astarting point for pharmaceutical care:

99mTcDTPA Renal Scans:. ‘gmTcGluconate Renal Scansc. 2“1ThalliumPerfusion Imagingd. ‘9mTcSulfur Colloid Liver Imaging

Appropriate objective data on a patient isrequired as part of the pharmaceutical careprocess. The most logical health practitionerthe nuclear pharmacist should communicatewith is:

nuclear medicine physician:. pharmacist cliniciac. nuclear medicine technologistd. patient’s nurse

Documentation of a pharmacist’s interventionsis mandato~, especially if reimbursement isdesired. In order to assist in thisdocumentation the following can be used:

Physician Progress Notes;. Pharmaceutical Care Plan Formc. Patient’s Medication Historyd. Nurse Progress Note

In order to strengthen your request forreimbursement, the “Discussion” section of thePharmacist Care Claim Form shouldinclude:

20 word narrative;. 150 word narrativec. numerical list of your intervention (1,

2, 3, etc.)d. SOAP NOTE

Typically, all that may be needed of apharmacist to obtain reimbursement forcognitive services is:

a. state Iicensureb. board certificationc. clinical hospital appointmentd. provider number

26