CAPPRE Primary Care Pharmacy Practice Collaborative��March 2025 Session��

ISU L.S. Skaggs College of Pharmacy

Center for Advancing Pharmacy Practice and Research Excellence (CAPPRE)

Agenda

• Welcome
• Community Practice Highlight
• Medical Billing Basics Topic Discussion
• Open Discussion

Welcome and Introductions

• Please add your name and practice site to the chat

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• ISU Staff:
• Primary Care Practice Section Lead:
• Jordin Millward, PharmD, BCPS, CDCES

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• CAPPRE Director:
• Zach Rosko, PharmD, BCPS

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• CAPPRE Intern:
• Mikayla Antonson, PharmD Candidate

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Community Practice Highlight:�

Medical Billing Basics�For Primary Care Pharmacists

Jordin Millward, PharmD, BCPS

March 19^th 2025

Medical vs. Pharmacy Billing

Major Medical Benefit

• Payment for the provision of health services that include prevention, diagnosis, or treatment of disease.
• Office visits
• Surgeries
• Lab tests
• Imaging
• Physical therapy
• Durable medical equipment (sometimes)
• Reimbursement through physician fee schedules, dictated by CMS and private payors (fee-for-service)
• Processed using CPT/HCPS codes

Pharmaceutical Services Benefit

• Covers prescription (sometimes OTC) drugs dispensed by a pharmacy.
• Medication costs
• Immunization costs (sometimes)
• Professional fees/dispensing fees
• PBM managed clinical services (MTMs, “statin” calls)
• PPS/DUR code requirements
• Durable medical equipment (sometimes)
• PBM controlled reimbursement (fee-for-product)
• Processed primarily using National Drug Codes (NDCs) and DUR/PPS

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Medical Coding

The Who on a Pharmacist Primary Care Claim

NPI

Up to 3 to consider:

• Rendering provider (who is responsible for providing the service)
• box 24j
• Billing provider (who gets paid)
• box 33a
• Referring/Ordering provider (who prescribed)
• box 17b

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Notes

• Generally only need 2 for most primary care claims
• Rendering/Billing*
• Rendering provider determined by who is recognized by the payer
• For Medicare services, it will not be a pharmacist!
• Billing provider is typically a group or facility

Medicare and Pharmacist Billing

Clinical Staff

• A person who works under the supervision of a physician or qualified health care professional who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service

Physician or other QHP

• An individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports the professional service

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Qualified Healthcare Providers (QHP) or Non-Physician Providers (NPP)

According to CMS, this list includes:

• Nurse practitioner (NP)
• Certified nurse specialist (CNS)
• Physician assistant (PA)
• Certified nurse mid-wife (CNM)
• Certified registered nurse anesthetist (CRNA)
• Clinical social worker (CSW)
• Physical therapist (PT)

Other payors may include pharmacists in this definition:

The Who on a Pharmacist Primary Care Claim

NPI

Rendering (box 24j)

• Pharmacist
• Physician/Non-Pharmacist Practitioner (NP/PA)
• Incident-to
• FQHC/RHC
• Hospital/Facility

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Billing (box 33a)

• Group (Clinic)
• Entity (FQHC/RHC)
• Provider Based Clinic

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ORP (box 17b)

• If entity listed, pharmacist is likely listed as referring/ ordering provider

The What on a Primary Care Claim

• Healthcare Common Procedure Coding System (HCPCS): standardized system to describe medical procedures, supplies, products, and services
• Created and maintained by CMS
• Level I: CPT codes, integrated into HCPCS framework
• Level II: Utilized for certain items, services, and non-physician care
• J codes: injectable drugs (e.g. J9202)
• E codes: durable medical equipment (e.g. E0114)
• G codes: Medicare-specific professional services (e.g. G2212)

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The What on a Primary Care Claim

• Current Procedural Terminology (CPT) codes: narrower set of codes that focuses on medical and diagnostic procedures
• Created and maintained by AMA and CMS
• Evaluation and Management (E/M) codes, procedural codes, diagnostic codes, treatment codes, lab codes, etc.
• Examples:
• Office visits (E/M): 99202 – 99215
• Emergency department visits (E/M): 99281 – 99288
• Hospital visits (E/M) (99221-99239)
• Preventative smoking cessation counseling: 99406, 99407
• Routine venipuncture: 36415
• CMP lab draw: 80053
• Vaccine administration: 90471, 90472
• MTM: 99605, 99606
• Chronic Care Management: 99490, 99493

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Evaluation and Management (E/M) Codes

• Used to describe services provided by healthcare professionals (HCPs)
• Evaluation of a patient’s health and management of their care
• E/M CPT codes are the most commonly billed in the US healthcare system
• Required elements of E/M evaluations
• Face to Face
• Request or referral from an appropriate source
• Chief complaint/consult problem
• Medically appropriate history and/or physical exam
• Written report submitted to request/referral source
• Level of service can be determined by:
• Time spent
• Complexity of medical decision making

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Time-Based Coding

• Time: all activities (face-to-face and non-face-to-face) related to the encounter preferred by the physician or qualified health provider (QHP) on the date of the encounter
• Obtaining external documentation
• Reviewing documentation
• Performing examination
• Counseling/educating the patient/caregiver
• Ordering medications, tests, procedures
• Documenting in medical record
• Do not include time spent performing activities normally completed by clinical staff
• The only time that can be included is time spent personally by the provider on the date of the encounter

Time-Based Coding: New vs. Established

New Patient

• 99202: minimum of 15 minutes
• 99203: minimum of 30 minutes
• 99204: minimum of 45 minutes
• 99205: minimum of 60 minutes

Prolonged services: codes billed in 15-minute increments beyond 99205

• +99417: minimum of 75 minutes
• G2212: minimum of 89 minutes
• Medicare-specific

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Existing Patient

• 99211
• Total time does not apply
• Intended for E/M of a patient that may not require presence of physician or QHP
• 99212: minimum of 10 minutes
• 99213: minimum of 20 minutes
• 99214: minimum of 30 minutes
• 99215: minimum of 40 minutes

Prolonged services: codes billed in 15-minute increments beyond 99215

• +99417: minimum of 55 minutes
• G2212: minimum of 69 minutes
• Medicare-specific

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MDM-Based Coding

• Medical Decision-Making: takes into account the complexity of medical decision-making, as measured by
• Number and complexity of problems addressed
• Amount or complexity of data to be reviewed/analyzed
• Risk of complications, morbidity, or mortality with patient management
• Terms used in MDM:

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MDM-Based Coding: New vs. Established

New Patient

• 99202: straightforward
• 99203: low
• 99204: moderate
• 99205: high

Existing Patient

• 99211
• Complexity does not apply
• Intended for E/M of a patient that may not require presence of physician or QHP
• 99212: straightforward
• 99213: low
• 99214: moderate
• 99215: high

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“Incident-To” Billing - CMS

• Services provided as part of the practitioner's professional services as part of treatment by auxiliary personnel
• Physician or QHP must have personally performed initial service
• Must establish a “plan of care”
• Physician or QHP must continue to be involved in treatment
• Physician or QHP should indicate service is medically necessary
• Most services must be directly supervised by billing physician
• Some services can be under “general supervision”
• Transitional Care Management (TCM)
• Chronic Care Management (CCM)
• Billing only 9921 (under-coding?)
• Billing higher than 99211 (going against CMS definitions?)

Other Billing Strategies

• Chronic Care Management (CCM)
• Applicable to Medicare beneficiaries with chronic conditions expected to last at least 12 months
• Practices can receive monthly fee of $40 per beneficiary
• Expected to spend 20 minutes per month on patient care activities
• Can be in person or over the phone
• Code: 99490
• Transitional Care Management (TCM)
• Pharmacists must collaborate with Medicare recognized provider
• Communication within 2 business days of hospital discharge
• Doesn’t have to be face-to-face
• Medicare QHP must be present at face-to-face within 7-14 days
• Code: 99495, 99496 (depends on complexity)

Other Billing Strategies

• Diabetes Self-Management Training/Education (DSMT/E)
• Program must be recognized by ADA or AADE for billing
• Requires comprehensive curriculum and outcomes tracking
• Codes:
• G0108: each 30 min of individual session
• G0109: each 30 minutes of group session
• Medicare Annual Wellness Visits (MAWV)
• Yearly visits required by Medicare
• Pharmacists can conduct AWV under direct supervision of QHP
• Follows incident-to rules, but reimbursement is much higher
• Many practices have nurse/mid-level/pharmacist conduct co-visit w/physician
• Codes:
• G0402: first annual wellness visit
• G0439: subsequent annual wellness visits

Medication Therapy Management

• Reimbursed through Medicare Part D, Medicaid, some private insurers
• Often no direct reimbursement to pharmacist
• Can contract with plans for a certain $ amount per patient
• CMS eligibility for MTM coverage
• Minimum of 2-3 chronic diseases (depends on plan)
• Minimum of 2-8 part D drugs (depends on plan)
• Likely to incur drug costs greater than MTM threshold ($1,623 for 2025)
• CPT codes:
• 99605: initial 15 minutes, new patient
• 99606: initial 15 minutes, established patient
• 99607: each additional 15 minutes
• Comprehensive medication review, targeted medication review
• Often time- and documentation-extensive

Reimbursement

The When (DoS)

• Date-of-Service
• In MM DD YY Format
• Should be on each line item
• Same date listed in both the From and To field

The Where (PoS)

• Place-of-Service Codes
• Common Codes in Primary Care
• 11 – Office
• 22 – Outpatient Hospital
• 50 – FQHC
• 72 – Rural Health Clinic

The Why on a Primary Care Claim

• International Classification of Diseases (ICD-10) codes: used to justify CPT and HCPCS codes via description and documentation of diseases, symptoms, and conditions
• Created and maintained by the World Health Organization (WHO)
• Different levels of specificity
• E11.9: type II diabetes without complications
• E11.65: type II diabetes with hyperglycemia
• E11.621: type II diabetes with foot ulcer
• Add-on code L97.421: non-pressure chronic ulcer of the right foot with skin breakdown
• Add-on code L97.422: non-pressure chronic ulcer of the left foot with skin breakdown
• Generally higher specificity = better

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The Why (ICD-10)

• Selecting the correct ICD-10 coding is complex
• Detailed instructions in the ICD-10-CM or online tool
• ICD-10-CM (cdc.gov)
• Often requires more than one code to describe a single problem/disease state
• Encounters with multiple services or problems addressed will require multiple codes
• Submitting an ICD-10 code on a claim not diagnosing
• Several CPTs (CCM/CCCM) require a minimum of 2 ICDs

Medical Necessity

• Billed services must be reasonable and necessary
• Diagnosis, treatment, cure, or relief of health condition
• Alignment with accepted medical standards
• Not for convenience of provider or patient
• Not experimental, investigational, or cosmetic
• Must align with ICD-10 codes and treatment plans
• Prior authorization can establish medical necessity
• Also meant to reduce redundancy in services
• Potential pitfall: “double dipping”
• Counseling/dispensing/DUR billed as part of bundled service
• Can’t bill E/M code for discussing HTN just because pt picking up HTN med

Medical Claim Revenue Cycle Basics

Remittance & Payment

• Documentation of encounter
• CPT/HCPCS codes for procedures/services
• ICD-10 codes for diagnosis/justification of medical necessity
• Place of service codes
• Modifiers (i.e. telehealth, CLIA-waived test)
• Claim created using EHR or separate billing software
• Formatted as CMS-1500 (clinic/outpatient) or UB-04 (hospital based)
• Rendering/billing providers indicated
• Claim submitted via:
• Clearinghouse (third-party)
• Insurer’s portal
• Paper claims can still be used

Remittance & Payment

• Once claim is submitted:
• Claim is approved, remittance advice and payment are issued
• Claim is denied and remittance advice is issued
• Request for additional information, claim put on hold
• Timeline (depends on payer):
• Expected payment: 15-60 days
• Appeal deadline for denials: 30-120 days
• Common denial reasons:
• Lack of medical necessity
• Claim filed late
• Missing or incorrect NPI
• Missing prior authorization
• Service is bundled into another billed code

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Electronic Remittance Advice (ERA)

• Electronic version of an Explanation of Benefits (EOB) sent to the provider after a claim is processed
• Contains:
• Payment details (amount paid, adjustments, patient responsibility)
• Denial codes or explanations for reduced reimbursement
• Utility:
• Allows for automated posting in billing software
• Helps identify denied or underpaid claims quickly
• Claim review/reconciliation ensures claims are paid as expected
• ERA and EFT (electronic funds transfer) automates a lot of the billing process

Fee Schedules

• Official list of Usual and Customary (U&C) fees in effect for each service offered
• Ensures
• Consistent treatment of patients and payers
• Compliance with contract terms and applicable laws
• Maximization of revenue
• Review or update regularly
• Yearly or with new contracts

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Idaho Medicaid Fee Schedule

Example Practice Fee Schedule

Self Pay Considerations

• Dual Fee Schedules (Self Pay and Insured)
• State/Federal law and/or payer contracts may limit or influence ability to have two fee schedules
• Often need to design self pay rate as a discount (% or flat rate) program vs a second fee schedule or establish a financial hardship program
• Have self-pay patients sign attestation of no insurance/no claim submission
• Review process against patient inducement, antikickback, false claims act and contract law provisions
• Self Pay Only Program
• Must still consider antikickback and inducement laws
• Ex: Drastically underpricing a medical service to generate sales or services under a federal benefit program

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How to Get Paid

• Ensure credentialing & contracts are in place
• Verify service eligibility with payor
• Is the pharmacist recognized?
• Is the service covered? Is it medically necessary?
• Select correct codes (E/M, CCM, etc.)
• Ensure ICD-10 codes support chosen CPT codes
• Evaluate time spent/medical decision making for E/M
• Submit under an approved provider if needed
• Ensure documentation meets payor standards
• Correct who, what, when, where, why of claim
• Submit claims in timely manner
• Track claim payments & follow up on denials
• Monitor ERA reports
• Address denials/underpayments in timely manner

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Resources

• References located under relevant slides
• AMA: CPT Code Search
• AAFP: E/M Coding (time and MDM)
• CMS: ICD-10 PDF and Resources
• ASHP: Pharmacist Billing/Coding Guide (a little out of date), Compensation and Sustainable Business Models Resources (members only)
• APhA: Incident-to Services, MTM Toolkit, Patient Care State Fact Sheets
• ID Medicaid: Pharmacist Provider Enrollment Guide

Discussion

Comments, Feedback or Questions?

Contact Us:

Zach Rosko: zacharyrosko@isu.edu

Jordin Millward: jordinmillward@isu.edu