7 basic facts about Pharmacy Billing Services

Physicians delivering healthcare are highly dependent on pharmacists to provide better service to patients. Although pharmacists had been known for conducting and being reimbursed for product-based practices, today, pharmacists play an important role in the healthcare delivery system that are needed to meet the goals of the ACA and CMS – minimize healthcare costs and improve healthcare delivery.

Pharmacists are improving their reimbursements with many roles and avenues, yet clarity in how to improve their Revenue Cycle Management (RCM) process is still lacking.

If you are looking to offer in-office dispensing to improve your revenue, here are some basic facts when it comes to Pharmacy Billing Services.

Fact 1.

To enable pharmacist reimbursement for healthcare services, including and following the Medication Therapy Management (MTM) CPT codes, negotiation specific contracts may be needed in non-institutional physician-based practices and clinics. On the other hand, pharmacist-based services may be included in pay for performance (PfP) incentives or a capitated payment model. If no specific contracts are present with private payers, pharmacy billing services automatically default to Medicare regulations.

Fact 2.

When Medicare beneficiaries are seen in a physician's office by a pharmacist, MTM COPT codes are not particularly recognized. Considering that physician offices fall under Medicare Part B, this might be the case. Medicare recognizes MTM services only under Part D. MTM Services are paid through administrative fees to a Prescription Drug Benefit Plan (PDBP) under Medicare Part D.

Fact 3.

If another entity has employed the pharmacist but it also practices in a physician-based clinic- pharmacists can then charge their services using incident -to billing in the physician-based clinic but need to follow the basic 9 requirements of Medicare.

Fact 4.

As part of the Affordable Care Act, a new Medicare program named Transitional Care Management was introduced on 2013 January 1st. The Transitional Care Management services are used to bill physician and “qualified non-physician providers” care management after an inpatient gets discharge from the hospital setting, observation setting, or skilled nursing facility. Pharmacists can serve as the “qualified non-physician providers” while offering some of these services. Yet, the claim for these services must be submitted under a Medicare recognized provider, so here, a pharmacist in this role needs to collaborate with a licensed Medicare provider. But, to request reimbursement for these services, 'incident-to' requirements need to follow by the pharmacist.

Fact 5.

A community pharmacy may bill for clinical/cognitive services which may differ by state and the Medicare Part D Prescription Drug Plans (PDP) available to them at their location. Various states pay community pharmacists to offer multiple levels of cognitive services to State Medicaid beneficiaries. But, community pharmacists may submit bills to any provider, but they require to decide which providers are eligible under a patient’s health insurance plan to submit bills, the rules of participation (a participation agreement might be necessary), and then standard procedures are to be followed in submitting the bill.

Fact 6.

Pharmacy services payments with state Medicaid programs change from state to state. The most common reimbursed services in the 15 states that offer Medicaid compensation for direct patient care are counseling, smoking cessation, and other preventive services

Fact 7.

The recent legislation passed in multiple states now enables community pharmacists to offer clinical services through collaborative protocols with physicians. But there are specific rules under which a pharmacist can practice. Services such as dosage adjusting and regimens, and medication monitoring, and changing prescriptions when required are normally acceptable throughout many states except a few. But, there is a narrow scope in the most collaborative protocols between a physician and a pharmacist which might limit pharmacist clinical services to specified patients and disease states.

Pharmacists need to practice in a range of varied environments and based on that, and the CMS rules & regulations, they need to go through the maze of billing policies and procedures to help increase their revenues.

We hope these facts will ensure minimal impact on pharmacy billing and coding services.

Read more: 5 Things About Pharmacy Billing & Re-Imbursements