CMS recently provided instructions on how pharmacists services provided in a physician office are billed on a 837P (electronic)/CMS-1500 claim form in the 2021 Physician Fee Schedule Rule published in the Federal Register on December 28, 2020. (See our newsletter of February 8, 2021).
However, there is no written guidance (CMS Rule or Transmittal) specifically addressing how pharmacists’ services provided in a hospital outpatient department should be billed.
We’ve received a number of questions particularly involving the billing of anticoagulation monitoring services on a 837I/CMS-1450 claim form when these services are provided as a hospital outpatient clinic visit.
We have compiled a list of key elements that should be considered when providing these services so that they are eligible for reimbursement. Please note that this information pertains to Medicare outpatient billing. For other payers, it is recommended that reimbursement rates are negotiated as part of the managed care contracting process and that specific documentation of pharmacists’ services should be agreed upon by both the facility and payer to substantiate the billing of the services provided.
1. The pharmacist must be acting within their scope of practice outlined in State rules and regulations for the state in which the facility provides services. This may include special certification (e.g. North Carolina Clinical Pharmacist Practitioner), and collaborative practice agreements.
2. Some States may have pilot or permanent programs for reimbursement that compensate a pharmacist on a monthly basis for total medication therapy based upon a risk-based member stratification. In general, if a patient has comprehensive MTM reimbursed under a monthly reimbursement to a pharmacist, additional reimbursement would not be available for a specific service such as anticoagulation management in a hospital outpatient department. One example is from Tennessee.
3. Elements of MTMS that are included in Medicare Part D payments cannot be included in billing from a hospital outpatient department for Part B services. For anticoagulation monitoring these services may have already been compensated when the prescription was filled under Part D: 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.
4. HCPCS code G0463 ((hospital outpatient clinic visit for assessment and management of a patient) was created in January 1, 2014 by CMS and replaced Current Procedural Terminology (CPT) Level I Codes 99201-99205 (new patient visit) and 99211-99215 (established patient visit) in the hospital environment for billing Medicare outpatients. Therefore, instead of being reimbursed based on the patient’s condition (acuity) or the types of hospital/nursing services rendered, all clinic visits were now paid a single flat rate. This code is only to be used to represent the hospital’s resources used for the clinic visit. The hospital is not required by CMS to use any specific criteria in determining a level of service since it is paid under a flat rate regardless of the intensity of the service provided. While this code change simplified the aspects of the billing process for hospitals, it did not eliminate the need for detailed clinical documentation. Clinical support staff should continue to document all pertinent information, including services and education provided. The documentation in the medical record should substantiate billing G0463 by the facility to represent overhead expenses incurred by the hospital. Therefore, if a provider is not paid by the hospital either as an employee or under a contracted arrangement, the hospital cannot bill for G0463 on the hospital claim.