Ensure smooth transactions in your pharmacy with our guide to Medical Codes for Pharmacy Billing. For 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 the 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 pharmacists 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. The use of MTM codes has not been widely adopted in ambulatory care because of a lack of reimbursement by third-party payers.
Medical Codes for Pharmacy Billing
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:
- 99605 -is to be used for a first-encounter service (up to 15 minutes)
- 99606 – is to be used for a follow-up encounter with an established patient (up to 15 minutes)
- 99607 – may be used with either 99605 or 99606 to bill additional 15-minute increments.
Besides these, certain modifiers used in pharmacy are essential to know. One of the most important modifiers when employed in 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 for 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 the 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.
Streamline your pharmacy’s financial workflow with our comprehensive guide on Medical Codes for Pharmacy Billing. Using certain codes when billing for pharmacy services is essential for building revenues now that 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 the 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 pharmacy billing and coding services will help concentrate on the core focus of improving patient health and thus reduce administrative and operational costs.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle management services. Our billing and coding experts are well-versed with the latest pharmacy billing updates helping you to receive accurate insurance reimbursements. To learn more about complete pharmacy billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226
FAQs:
CPT codes are standardized codes used by pharmacists for billing interventions, ensuring accurate reimbursement for services like medication therapy management and patient consultations.
The primary codes for MTM services include 99605 for first encounters (up to 15 minutes), 99606 for follow-up encounters (up to 15 minutes), and 99607 for additional 15-minute increments.
The JW modifier indicates the amount of a drug that was discarded and not administered. It should be used when drug wastage occurs but not if no drug was administered or if the dose is less than the billing unit.
Knowledge of medical coding can streamline billing processes, enhance revenue cycle management, and ensure accurate insurance reimbursements, allowing pharmacies to focus on patient care.
MBC provides comprehensive revenue cycle management services and expert guidance on the latest pharmacy billing updates to help pharmacies achieve accurate insurance reimbursements.