Billing for Pharmacists’ Services provided in a Physician Office 2/8/21

The Physician Fee Schedule (PFS) Final Rule was published in the Federal Register on December 28, 2020 and includes instructions on the billing of services provided by pharmacists “incident to” physicians’ services when provided in the physician office setting (Place of Service Code=11). These services are billed by the physician on a 837P or CMS-1500 claim form. 

The rule includes the following clarifications:

• Medication management is covered under both Medicare Part B and Part D.

• When the services are provided and paid under the Part D benefit, the services are not also reportable or paid for under Part B.

• Pharmacists fall within the regulatory definition of auxiliary personnel under CFR Title 42 Section 410.26.

• Payers other than Medicare may consider pharmacists to be a qualified health care professional (QHCP) and provide direct payment, but there is no Medicare statutory benefit allowing pharmacists to enroll, bill and receive direct payment for Physician Fee Schedule (PFS) services.

• Pharmacists are not among the physicians and QHP’s that can furnish and bill for the 2021 office/outpatient E/M visit codes because levels two through five (99202-99205) are by definition only performed and directly reported by physicians or QHP’s. For example, when time is used to select visit level, only the time of the physician or QHP is counted. 

• Pharmacists may provide services “incident to” the services of physicians or NPP (non-physician practitioners) and they must be an integral part of the service of a physician (or other practitioner) in the diagnosis or treatment of an injury or illness. 

• Pharmacists must provide services under the appropriate level of supervision (direct), and must be acting within their scope of practice and any applicable laws or rules and regulations.

• When medication management is offered as part of the Part D benefit, Part B payment is also not available for services included in the Medicare Part D dispensing fees:

  • pharmacist’s time in checking the computer for information about an individual’s coverage, 

  • measurement or mixing of the Part D drug, 

  • filling the container, and

  • physically providing or delivering the completed prescription to the Part D beneficiary

  • screening for potential drug therapy problems due to therapeutic duplication, age/gender-related contraindications, potential over-utilization and under-utilization, drug-drug interactions, incorrect drug dosage or duration of drug therapy, drug-allergy contraindications, and clinical abuse/misuse

• CPT code 99211 (may not require the presence of a physician or other qualified health care professional and is used when the presenting problem(s) are minimal) may represent services provided by the pharmacist. Code 99211 has a status indicator of “B” in the OPPS and is therefore not recognized for payment in hospital outpatient departments, but is payable in physician office settings.

CMS agreed with some commenters that under the general CPT framework, pharmacists could be considered QHPs or clinical staff, depending on their role in a given service. However, CMS reiterated that under the current Medicare law, CMS does not have the ability to pay (or even price) services that are furnished and billed directly by pharmacists. CMS did acknowledge that new coding might be useful to identify particular models of care (e.g. collaborative practice agreements) in the future.

SHOUT-OUTS

1. Under current Medicare law, pharmacists may provide clinical services in a physician office setting incident to the professional services or other NPP similar to other clinical staff and within their scope of practice, but the physician or NPP is limited to billing only CPT Code 99211 for these services as levels two through five can only be performed and reported by a QHP. 

2. Current Medicare Law does not allow pharmacists’ services to be billed directly to CMS when furnished in a physician office.

3. Services included in the payment of Part D benefits cannot also be billed to Part B and include some medication therapy management services in addition to preparation and dispensing of the drug.

4. Other payers may have different instructions on billing for pharmacists’ services or individual agreements may be negotiated with commercial payers.