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Pharmacy Billing Coding Updates You Can’t Afford To Miss In 2018

By Author: Steave Martin
Total Articles: 33

The pharmacy practice is evolving along with changes in the healthcare industry. With this transformation, the supply and demand factors related to pharmacy services are also transforming. In the coming days, patient demands on the healthcare procedures are expected to increase ominously and outpace the current provider supply nexus. Team-based approaches have been regarded as a key policy to meet the future and current pharmacy medical billing prerequisites.

Pharmacists today are progressively giving patient care services in a variety of settings, right from inpatient, outpatient/ambulatory clinics to community pharmacies. All of them are gradually providing services distinct from the traditional prescription dispensing units and offering patient care services such as:


Point-of-Care (POC) testing

Medication Therapy Management (MTM)

Chronic care management

Transitions of care management

Patient education and counseling as well.

Do remember that state wise regulations stipulate the provision of the scope and types of procedures that can be delivered by pharmacists.

By tradition, pharmacist-provided patient care services have most commonly been billed to payers or health plans such as Fee for Service (FFS) methodology. But, professional pharmacy medical billing and reimbursement is facing limited timeline options. Pharmacists who provide clinical services in an FFS care setting do bill Medicare Part B, State Medicaid Programs and other payers using American Medical Association (AMA) Current Procedural Terminology (CPT) codes as they fall under the physician billing processes.

According to the Medicare Modernization Act of 2003 (MMA), the Medicare Part D program made it compulsory for Prescription Drug Plans (PDP) and Medicare Advantage Plans (MAPDs) to create and implement an MTM program. Consequently, CPT codes specific to Medication Therapy Management were developed.

Another vital pharmacy billing update for 2018; to support the team and value-based billing of patient-care services, specific documentation of the diagnosis, service, complexity of service, etc. is mandatory. Some conditions are defined in the CPT and Healthcare Procedure Code System (HCPCS) codes; others are demarcated in specific program requirements.

Pharmacy billing methodologies you can’t miss in 2018!!

There are various methods for billing and coding pharmacist patient care services in 2018. The use of a particular method is reliant to some extent on the type of benefit providing coverage for the procedures, provider-payer contracts, care settings, and professional service agreements.

Reimbursement based on contract

Pharmacies may receive reimbursement based on contracts with insurers or by professional service agreements with/or between providers. Reimbursement rates and coding methodology are conveyed between the pharmacy and the healthcare payer/provider. As of now, there is little standardization in these agreements. Compensation may be fee-for-service or may be covered under a global rate.

Charging Patients Directly

Pharmacists may bill patients directly for their services on a cash transaction basis. The cost structure is formed by the pharmacist. Patients pay for the procedures and drugs out of pocket and may receive documentation to obtain the potential refund from their health plan.

Delivery of the pharmacy billing

Services provided by the pharmacist in 2018 are delivered across various settings of patient care such as a physician office or clinic. This comes under the supervision of and in collaboration with a doctor or a certified practitioner. A perfect way to bill in these settings is ‘incident to’ billing where the practitioner or clinic charges for the services of the pharmacist as ‘incident to’ the practitioner or clinic service.

Pharmacy billing codes are found in the HCPCS and the Level I of American Medical Association CPT Codes. You must also know that specific codes were developed in 2005 for the payment of an MTM service provided by a pharmacist. These codes are not used under Medicare Part B but can be used by Medicaid, private insurance providers or Medicare Part D plan administrators in determining reimbursement for services.

The 2018 pharmacy billing and coding methodology available to practices are where pharmacists either are or serve as part of a patient care team.

At Medical Billers and Coders our experienced team of specialty billers and coders assure you of a profitable revenue cycle by minimizing the errors through auditing and submitting clean reimbursement claims.

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