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.
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.
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.
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
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
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.
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
"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 
visit," she said.
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.
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.