CMS tells family physicians that pharmacist-provided services may be billed as incident-to

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Agency’s letter strengthens pharmacists’ role in team-based care within patient-centered medical homes, American Academy of Family Physicians president says

CMS has informed the American Academy of Family Physicians (AAFP) that a physician may bill the Medicare program for pharmacist-provided services as incident-to services if all the legal requirements are met.

In a March 25 letter, CMS Administrator Marilyn Tavenner, BSN, MHA, confirmed AAFP’s impression that a physician may bill Medicare for a Part B–covered service provided by a pharmacist in the practice. The agency’s official stance came in response to a January 22 inquiry by AAFP that mentioned family medicine’s increasing emphasis on team-based care that’s being encouraged by Medicare and other payers, especially in the context of a patient-centered medical home.

“This new position by CMS really strengthens the pharmacist’s role in team-based care within patient-centered medical homes,” AAFP President Reid B. Blackwelder, MD, told pharmacist.com. “It just clarifies that CMS recognizes how important it is for pharmacists to be on the front lines with us as physicians in making sure patients have access to the care that they need.”

AAFP wrote in its inquiry that incident-to services are defined by Medicare as services and supplies in a noninstitutional setting that are an integral, although incidental, part of the physician’s professional service; commonly rendered without charge or included in the physician’s bill; of a type that are commonly furnished in physician’s offices or clinics; and furnished by the physician or auxiliary personnel under the physician’s direct supervision.

AAFP continued that it could not find anything that would exclude pharmacists from Medicare’s definition of auxiliary personnel.

CPT codes for evaluation and management for outpatient visits commonly used in physician practices include 99211–99215, and may be referred to as level 1–5 visits, according to a March/April 2012 Journal of the American Pharmacists Association article on billing for pharmacists’ cognitive services in physicians’ offices. “Because pharmacists do not have provider status, CPT codes higher than a level 1 visit are not routinely allowed by most insurance companies.”

The inquiry by AAFP came about when a physician who “felt pharmacists should be able to receive compensation for their time in providing patient care as part of the primary care team” took the issue to AAFP, said Lyndsey N. Hogg, PharmD, BCACP, Clinical Pharmacy Specialist in Ambulatory Care at Via Christi Health Inc. in Wichita, KS.

Hogg said that ambulatory care pharmacy services began at her institution almost 2 years ago, focused in three patient-centered medical home pilot clinics. “At that time, we had extensive discussions regarding options for billing for our services,” she explained in an e-mail. “One of the main avenues for billing we pursued was incident-to the provider (99211 specifically). After extensive review, research, and discussion, our organization opted not to bill for our pharmacists’ appointments. It had been determined 99211 was not an option,” which prompted the physician champion to approach AAFP.

A committee at AAFP then conducted their own research and developed a letter to CMS, according to Hogg.

Hogg thought the letter was “a good starting point to again bring about discussion regarding reimbursement for cognitive services provided by pharmacists, especially in the clinic setting.”

Like Hogg’s physician champion at Via Christi Health in Kansas, AAFP’s Blackwelder also works with a pharmacist in his clinic—a family medicine residency program in Kingsport, TN. Blackwelder referred to the pharmacist as “a great clinician [who] helps me take care of my patients.”

Then the AAFP President circled back to the importance of Tavenner’s letter. “I just think this is a move in the right direction,” Blackwelder said. “I hope this continues to help CMS make other decisions to help reinforce the value of team-based care.”

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