Pharmacist Billing for Ambulatory Pharmacy Patient Care Services in a Physician Based Clinic

It is well known that Pharmacists have now become integral members of healthcare teams across various settings, such as patient-centered medical homes, community health centers, long-term care facilities, and hospital outpatient departments. There is also a wide and growing recognition that ambulatory care pharmacy services go much beyond the mere dispensing of medications and have evolved to include direct patient care, designing and managing of complex medication regimens, and care delivery systems.

Nearly all case studies and surveys demonstrate that including pharmacists practicing in ambulatory care settings on the healthcare team improves quality of care, enhances patient outcomes, and reduces cost overheads. Nearly all US states now allow pharmacists to provide direct patient care services under a physician–pharmacist collaborative agreement, further supporting the expansion of ambulatory care pharmacy services

Although medical billing & coding in the pharmacy healthcare service is not straightforward and can be very complex, yet having an understanding of how the Revenue Cycle Management process works, and knowledge of the domain helps bring in more revenue. It is noteworthy to note that Pharmacists can bill for services in hospital-based clinics using CPT Evaluation and Management (E&M) Codes 99211-99215 for facility billing (Facility billing is the hospital's technical charge for services provided in an outpatient department of a hospital and represents "hospital resources utilized). Here, a pharmacist can bill "incident to" a physician in this practice setting utilizing facility fee only billing (no professional fee for the pharmacist services)

However, in physician based clinic, ie a non-hospital based clinic, especially when it comes to Medicare patient, pharmacy billing is not governed by Hospital Outpatient Prospective Payment System (HOPPS) regulations but instead is governed by a number of CMS rulings. Earlier pharmacists were not permitted to bill Medicare patient in a non-hospital based clinic under Medicare part B. But in mid-2013 CMS permitted that physicians may bill Medicare for a Part B–covered service provided by a pharmacist in the physician practice, as incident-to services if all the legal requirements are met as per CMS rules & regulations. However, Medication Therapy Management Services (MTMS) is excluded from Part B covered benefits and may only be reimbursed by a beneficiary's Medicare Part D or Medicare Advantage plan. Further, the existing MTMS codes developed for specific purposes have their own limitations given that MTMS programs of the type covered by Part D drug plans are not generally provided in medical practice settings, and because of wide variance in their benefit designs. Additionally, new Medicare billing codes have been created in the latter half of 2014 to support policy objectives contained within the Affordable Care Act. These include activities in Transitional Care Management (TCM), Chronic Care Management (CCM), and other incident-to rule changes

Moreover, in order to bill for services, the clinician providing the service is no longer required to be employed by/contracted with the physician, NPP, or the practice. Due to the nature of CCM and TCM services, the supervision requirement is now much looser. Physicians and NPPs are no longer required to be onsite for services to be rendered. The point is for CCM and TCM services to be available to patients 2 4/ 7.

It should be remembered that the Incident-to requirements often vary based on the type of service provided. The complexity in pharmacy billing comes when to know which service cannot be billed incident-to, and which can be billed incident-to may, as it all varies and depends on the health care setting. A deep knowledge and expertise in the medical coding and billing of pharmacy services is essential for a pharmacist to thrive in the present economy.

Below is a short summary of Service, codes and the physician based settings

Billing option CPT Billing Code Service Description

Incident -to physician:
Evaluation and
Management (E/M)


Office or other outpatient visit (face -to-face) for the evaluation and management of an established patient that may not require the presence of a physician

Medicare Wellness Visit (MWV)

G0438 (First MWV)
G0439 (Subs

Comprehensive interview and plan development (e.g., family and medical history, medication reconciliation, routine vital signs, preventive screening schedule, risk -
factor assessments)

Transitional Care
Management (TCM)

complex: w/in
14d D/C)
99496(Highly complex: w/in 7d D/C)

Series of interactive, face-to-face, and non-face-to-face communications with beneficiary and/or caregiver to coordinate care (obtain and review discharge information; conduct medication reconciliation and management; review and reinforce plans for follow-up, diagnostics, and
treatments; coordinate with other health care professionals, agencies, and community services used by the beneficiary; etc.

Chronic Care
Management (


Extensive service including a structured recording of patient health information, an electronic care plan addressing all health issues, access to care management services, management of care transitions, and coordination
and sharing of patient information with practitioners and

providers outside the practice

Medication Therapy
Management Services

99605(New pt)


(Est pt)


Medication therapy management service(s) provided by a pharmacist, individual, face -to-face with patient, initial 15 minutes, with assessment, and intervention if provided; initial 15 minutes

Each additional 15 minutes (list separately in addition to code for the primary service/in conjunction with 99605, 99606)

Adapted from:

Published By - Medical Billers and Coders
Published Date - Jun-01-2016 Back

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