Pharmacy News

Pharmacists Praise New Medicare Billing Opportunities

[January 15, 2015, AJHP News]

Kate Traynor

BETHESDA, MD 23 Dec 2014—Recent updates to the incident-to billing requirements from the Centers for Medicare and Medicaid Services (CMS) have created new opportunities for medical practices to be reimbursed for pharmacists' patient care services.

"Change is happening," said Sandra Leal, medical director of pharmacy at El Rio Community Health Center in Tucson, Arizona. "What's exciting is that there is more consideration from CMS to have pharmacists participate in teams and to . . . bill with the physician," she said.

Sandra Leal

Leal said the new billing opportunities arise from clarifications from CMS on work done by nonphysician healthcare providers and language in the agency's 2015 update to the physician fee schedule.

The fee schedule, released this past November, allows physicians to bill Medicare for unsupervised after-hours services provided by nonphysicians under Medicare's chronic care management (CCM) and transitional care management (TCM) programs. The person who provides these services incident to a physician's care need not be a direct employee of the medical practice, according to CMS.

TCM and CCM services involve face-to-face care and comprehensive follow-up, including medication therapy management, within a specific time frame.

CMS began reimbursing medical practices for TCM services in 2013, and Leal said her clinic participates in this program. She said in November that no decision had yet been made about providing CCM services.

"Our compliance officer is actually reviewing the language right now to see if it makes sense for us to be able to participate," she said.

The 2015 fee schedule doesn't state outright that physicians can bill for pharmacists' TCM and CCM services provided incident to the physician's care. Instead, the fee schedule refers to physicians' clinical staff and the time spent by those nonphysician healthcare professionals in providing TCM and CCM services.

But a March 2014 letter from CMS Administrator Marilyn Tavenner affirmed that pharmacists are among the nonphysician healthcare providers for whom incident-to billing is permissible [see June 15, 2014, AJHP News].

CMS regulations for 2014 also specified that nonphysician healthcare professionals must meet state requirements for licensure and work within their state's scope of practice regulations in order to participate in incident-to billing.

Betsy Bryant Shilliday, associate professor of medicine at the University of North Carolina (UNC) School of Medicine in Chapel Hill and assistant medical director for the UNC internal medicine clinic, said the reference to state law has greatly benefited her clinic.

Betsy Shilliday

That's because North Carolina has established the clinical pharmacist practitioner (CPP) credential, an advanced-practice designation conferred by the state's pharmacy and medical boards.

Under North Carolina state law, CPPs are "approved to provide drug therapy management, including controlled substances, under the direction of, or under the supervision of a licensed physician."

Shilliday said her regional Medicare carrier—or Medicare administrative contractor (MAC), as the entities are officially designated—recently agreed that CPP-certified pharmacists qualify for incident-to billing using higher-level Current Procedural Terminology (CPT) codes.

Specifically, she said, physicians can bill using CPT codes 99211–99214 for pharmacists' incident-to services.

"This was my Christmas present. I'm like a kid in a candy store now," Shilliday said in November.

Shilliday recalled that about a decade ago, her Medicare carrier allowed higher-level incident-to billing by pharmacists. But that changed when a different carrier assumed responsibility for the region.

At that time, she said, pharmacists' services were restricted to the minimal evaluation and management CPT code, 99211, regardless of the time spent with the patient and the complexity of the patient's condition or the medical decision-making involved in the visit.

"We'd been going along that path, providing very complex care but getting reimbursed very little," Shilliday said. "So it's been very hard for us to justify to practices to hire more pharmacists, because we're expensive. And our reimbursement rates are very low, especially if we're in a high Medicare population clinic."

She said the new ruling from the MAC will provide a better return on the clinic's investment in pharmacists' services. Her compliance office is also attempting to justify billing at the highest level, 99215.

"However, we're happy to bill up to a 99214. It's huge, it's over three times what we are able to bill for a [99211] visit," she said.

Shilliday said that although the CPP credentialing process for North Carolina pharmacists helped sway the Medicare carrier's approval of higher-level billing, pharmacists in states without a similar advanced practice designation might also be able to use higher-paying CPT codes.

"I would very much explore it in another state as well and see how they interpret it. Because each Medicare carrier can interpret it differently," she said.

Shilliday said she and her colleagues are exploring whether the clinic meets CMS's requirements to bill for TCM and CCM services. She said potential problems with billing for these services include the need to obtain a written agreement from patients to receive the care. Medicare coinsurance and deductibles apply to TCM and CCM services, which could pose an obstacle to patients' acceptance of the services.

Shilliday and Leal welcomed the new opportunities for reimbursement of pharmacists' patient care services. But they emphasized that incident-to billing is not a substitute for the recognition of pharmacists as healthcare providers under the Social Security Act.

Shilliday noted that her MAC's previous refusal to allow higher-level billing for pharmacists' incident-to services was based on the fact that CMS didn't list pharmacists as recognized providers.

Leal explained that incident-to billing "only covers what the provider specifically asks for you to help with."

If a physician refers a patient to a pharmacist for diabetes management, only those services are billable as incident to the physician's service. This applies even if the pharmacist discovers during the encounter that the patient has uncontrolled hypertension or other problems and addresses those.

"You will [treat them], because that's our clinical obligation. But for reimbursement purposes, you're only able to do what the [physician] asks you to do," Leal said.

Thus, to allow pharmacists broader opportunities to use their skills and be reimbursed for their work, "it's very critical to get provider status," Leal said.


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