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Pharmacists Get Good News About Medicare Part B

  • February 17, 2016
  • RPh on the Go

medicare_part_b_pharmacyThe 2016 Medicare Part B payment policies, issued by the Centers for Medicare and Medicaid Services (CMS), recently delivered good news for some pharmacists. The CMS has maintained the centralized service billing option for those pharmacists’ who work in anticoagulation clinics. They also made the payment policy for biosimilars comparable to the policy in place for multiple-source drugs. Additionally, there seems to be a willingness on the part of the CMS to recognize the labor of those pharmacists working in an ambulatory care setting as being part of the physician practice’s direct cost.

While the CMS was reviewing the policies for 2016, they were implored by practitioners and members of the public not to remove a single line within the regulation that stated: “The physician… supervising the auxiliary personnel need not be the same physician…upon whose professional service the incident to service is based.” CMS was considering removing it in order to clarify which physicians were allowed to bill Medicare for specific services. They had stated they believed only the physician directly involved with care could bill for that service, or a physician supervising other personnel.

However, the American Society of Health-System Pharmacists, or ASHP, made the point that removing the sentence would likely be detrimental to ambulatory care practice sites, as well as anticoagulation who utilized centralized billing. They further pointed out that the physician or practitioner at these locations might not be the one who originally ordered the service. The portion of the regulation has now been amended to say that the practitioner or physician supervising the auxiliary personnel does not need to be the provider responsible for “treating the patient more broadly.”

Unfortunately, several of the other concessions the ASHP was hoping to received did not go as well. One expert indicated that the response received from the CMS was not entirely negative. There appears to be a request for more information in the form of a white paper from experts outlining the needs and costs associated with adding pharmacists’ clinical labor costs.

In regards to the question about billing under the services incident to physicians’ services, the CMS remained resolved in their stance on code 99211. This is still considered the highest level of payment for services provided by a pharmacist incident to those provided by the physician. An expert at Purdue University of College of Pharmacy, Gloria Sachdev, said billing practices required specific language to be approved. When discussing billing it is important to say that the pharmacist is acting as auxiliary personnel and will meet all the incident to criteria, followed by a list of the relevant criteria. This lets the billing personnel know that the pharmacist wishes to bill Medicare with the evaluation and management (E&M) code rather than an MTM code, which is not payable by Medicare.


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