Although, pharmacists have always been looked upon as conducting and being reimbursed for product based practices, yet today, they play a very essential role in the healthcare delivery system that are essential to meet the goals of the ACA and CMS – reduce healthcare costs and improve healthcare delivery. But despite the many roles and avenues that are present for pharmacists to improve their reimbursements, yet clarity in how to enhance their Revenue Cycle Management (RCM) process is still lacking.  Here are some basic facts when it comes to billing for Clinical Pharmacy Services


To enable pharmacist reimbursement for patient care services, which may include incorporating the Medication Therapy Management (MTM) CPT codes, negotiation specific contracts are required in non-institutional physician-based offices and clinic. Alternatively, pharmacist-based services may be included into a pay for performance (PfP) incentives or a capitated payment model. If there are no specific contracts with private payers, billing for pharmacy services automatically defaults to Medicare regulations.

Fact 2:

If a pharmacist is employed by another entity but also practices in a physician-based clinic- pharmacists can then bill their services using incident -to billing in the physician-based clinic but keeping in mind the basic 9 requirements of Medicare.

Fact 3:

MTM CPT Codes are not recognized especially when Medicare beneficiaries are seen in a physician office by a pharmacist, given that physician offices fall under Medicare Part B. Medicare recognizes MTM services only under Part D. Under Medicare Part D, MTM services are paid through administrative fees to a Prescription Drug Benefit Plan (PDBP).

Fact 4:

A community pharmacy may bill for clinical/cognitive services which may vary by state and the Medicare Part D Prescription Drug Plans (PDP) available to them at their location. Several states pay community pharmacists to provide various levels of cognitive services to State Medicaid beneficiaries. However, community pharmacists may submit bills to any provider, but they would need to determine which providers are eligible under a patient’s particular health insurance plan to submit bills, the rules of participation (they may need to sign a participation agreement)  and then standard procedures would need to be followed in submitting the bill.

Fact 5:

As part of the Affordable Care Act, a new Medicare program called the Transitional Care Management was introduced in January 1, 2013. The Transitional Care Management services are used to bill physician and “qualified non-physician providers” care management following discharge from an inpatient hospital setting, observation setting, or skilled nursing facility. Pharmacists can serve as the “qualified non-physician providers” to provide some of these services. However, the claim for these services must be submitted under a Medicare recognized provider, so a pharmacist in this role must collaborate with a licensed Medicare provider. However, to request reimbursement for these services, the pharmacist must meet the “incident-to” requirements

Fact 6:

Although recent legislation enacted in several states now enables community pharmacists to provide clinical services through collaborative protocols with physicians, yet specific rules exists under which a pharmacist can practice. Services like medication monitoring, dosage adjusting and regimens, and changing prescriptions when required are quite commonly acceptable across most states but for a few exceptions. But, most collaborative protocols between a physician and a pharmacist are narrow in scope, limiting pharmacist clinical services to specified patients and disease states.

Fact 7:

Payments for pharmacy services provided through state Medicaid programs vary from state to state. The most commonly reimbursed services in the 15 states that provide Medicaid compensation for direct patient care include smoking cessation, counselling, and other preventive services


Pharmacists practice in a variety of settings and based on that, and the CMS rules & regulations, they have to navigate through the maze of billing policies and procedures to help increase their revenues. Having the facts in place will ensure minimal impact on pharmacy billing and coding services

Published By - Medical Billers and Coders
Published Date - Jun-03-2016 Back

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