Top Medical Codes for Pharmacy Billing



For a successful and effective billing in pharmacy, efficiency in coding is of paramount importance. Pharmacists have been using CPT codes for seeking reimbursement thus far for interventions such as reviewing a patient’s history, creating a medication profile for a patient, and making recommendations to a patient for improving compliance with therapy.

The billing of appropriate CPT codes involves Assessment of Drug-related needs, Identification of Drug Therapy Problems, Complexity-of-Care Planning, and Approximate Face-to-Face Time.

It was in July 2005 that the AMAM CPT Advisory Panel released a new set of codes for use by pharmacist for Medication Therapy Management (MTM) Services and in November 2006 these Category III codes were changed to Category I till recently.  Currently, the most common methods for billing for pharmacist services in physician offices involve facility fees in hospital-based clinics and the “incident to” model in private practice. Use of MTM codes has not been widely adopted in ambulatory care because of lack of reimbursement by third-party payers.

Three (3) ‘pharmacist only’ CPT professional service codes to bill third-party payers for MTM Services delivered face-to-face between a pharmacist and a patient:

  1. 99605 -is to be used for a first-encounter service (up to 15 minutes)
  2. 99606 – is to be used for a follow-up encounter with an established patient (up to 15 minutes)
  3. 99607 – may be used with either 99605 or 99606 to bill additional 15-minute increments.

Besides these, certain modifiers used in pharmacy are very essential to know. One the most important modifiers when employed in the pharmacy billing and coding, is the HCPCS modifier JW which is defined as “drug or biological amount discarded/not administered to any patient” and is used on claims to indicate drug wastage. The JW modifier is only to be applied to the amount of drug/biological discarded. It should be noted that the amount administered and the amount wasted must always be billed on the same claim. However, certain criteria are used from employing the JW Modifier:

a)The modifier JW should not be used for claim billings when the actual dose of the drug/biological administered is less than the billing unit established by HCPCS description

b)Drug wastage cannot be billed if none of the drug was administered (for example if a patient has missed their appointment)

c)The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP)

However, a check with one’s respective state Medicare carriers needs to be looked at before applying modifier JW.

Using certain codes when billing for pharmacy services is essential for building revenues now that the Medicare has included physicians as part of the healthcare providers who can provide services to patients and can thus bill directly. An added advantage of knowing complexities of billing and coding can go a long way to building an efficient and effective Revenue Cycle Management (RCM) process for pharmacy. If working as a retailer or from a hospital premise, outsourcing of pharmacy billing and coding services will help concentrate on the core focus of improving patient health and thus reduce administrative and operational costs.

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