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      Outcomes Needs Lab Monitoring or Health Test TIPs

      Targeted Interventions: 

      • Blood Pressure Measurement
      • Hemoglobin A1c (HbA1c)
      • Lipid Panel 

      Overview 

      Needs Lab Monitoring or Health Test TIPs prompt pharmacists to assess and address the need for clinical monitoring based on the patient's existing health conditions. These TIPs aid in proactive chronic disease management and help close care gaps. There are multiple quality measures health plans are trying to impact by collecting these health test results as well. 
       
      By conducting or facilitating lab monitoring and health screenings, pharmacists contribute directly to early detection, disease management, and care continuity. This service highlights the evolving role of pharmacists as healthcare providers and reinforces trust between patients and the pharmacy team. 

      Completion Requirements for Health Test TIPs: 

      To complete this TIP successfully, the following steps must be taken: 

      1. Assess Appropriateness:
        a. Confirm the patient is an appropriate candidate for indicated screening. 
      2. Make a Clinical Recommendation:
        b. Recommend the screening if clinically appropriate. 
      3. Facilitate the Test:
        a. Perform the test in the pharmacy or
        b. Refer the patient to another healthcare provider and confirm completion. 
      4. Record the Result:
        a. Enter the health test result value in the specified format. 
      5. Educate the Patient:
        a. Explain the results and discuss normal/target parameters and levels. 
      6. Timely Documentation:
        a. Document the provider’s name if the screening was completed in the pharmacy & share  the results with the patient's primary care provider.
        b. Document the date the health test was administered.
        c. Document the date the outcome was determined (must be within 30 days of the date the health test was administered).
        d. Detail patient specific information in the 'Severity Level and Rationale' section
        e. Indicate if the heath test/measurement was completed at your site.
        f. Indicate if you are seeking reimbursement for supplies from another source.
        g. Submit the claim 

      Frequently Asked Questions 

      Q: Can any type of A1c test be used? 
      A: Yes. There is no specific brand limitation. Any CLIA-waived test is acceptable. 

      Q: Can manual or automatic BP machines be used? 
      A: Both manual and automatic BP collection methods are acceptable as long as results are collected at the pharmacy or by another healthcare professional based off the pharmacist's recommendation and recorded correctly. 

      Q: Are pharmacists required to send results to the patient’s PCP? 
      A: Yes, if the test was administered in the pharmacy. A documentation field in TIP workflow is provided for the PCP’s name. 

      Q: Are technicians allowed to provide the service for these TIPs? 
      A: Only licensed pharmacists may perform the service – either by completing the health test in the pharmacy or referring the patient to another healthcare provider. Technicians may assist with the documentation of the test results collected by a healthcare professional.  

      Q: What about states that don’t allow pharmacists to perform A1c tests? 
      A: In states that don't allow pharmacists to perform A1c tests, a patient self-administered test is allowable under pharmacist supervision. Language and workflow may vary slightly by state—teams should refer to their state board’s regulations. 
      You can also refer the patient to get the test from another provider and record the results once completed. 

      Q: Can I document the result of a test the patient recently completed?  
      A: No, the health test must be done as the result of your recommendation to be a payable intervention.  

      Q: Can the patient report a blood pressure reading they took at home?  

      A: No, the test must be completed with a healthcare professional. 

      Q: Do I need a CLIA waiver for my pharmacy to perform A1c or other lab tests? 

      A: Your pharmacy may need to obtain a CLIA waiver to perform point-of-care (POC) lab testing such as HbA1c, blood glucose, cholesterol, or rapid strep/flu tests.  

      Q: How do I obtain a CLIA waiver? 

      A: Pharmacies apply through their state agency or CMS (Centers for Medicare & Medicaid Services) https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/howobtaincertificateofwaiver.pdf  

      Q: Are CLIA waivers required for blood pressure screenings? 

      A: No, blood pressure measurement is not considered a lab test and does not require a CLIA waiver. 

      Best Practices for Claim Approval 

      • Ensure the health test value is reasonable and documented as XXX/XX mmHg for blood pressure and X.X% for A1c tests.
        • If the value is unusually high or low, include supporting notes to explain the result. 
      • Only document health test values that were obtained as a direct result of your recommendation to complete the test. 
      • The encounter date must not precede the date the health test was administered.
        • Encounter date is the date the health test result was determined. 
      • Only document health test values that were collected within the past 30 days.
      • Monitor Review & Resubmit for any claims that require clarification. 

      High Blood Pressure Resources 

      Diabetes Resources