Although alternative payment models (APMs) are increasingly being used as a reimbursement method, fee-for-service (FFS) and use of HCPC codes remain prevalent in most practices. Since Medicare rules are considered the gold standard for medical billing and the accepted method used by most commercial payers, the discussion herein will focus primarily on Medicare billing options and regulations for pharmacist patient care revenue. It is important to note that commercial payers and state Medicaid may not recognize all Medicare codes, or they may include billing codes within their benefit plans not used by Medicare. The billing codes that may apply to your practice require investigation at the local level to determine what is available for payers in your location and patient population. Generating revenue in a FFS model for pharmacists is dependent on the site of practice (i.e., a health system/hospital outpatient clinic, an independent physician or physician group office or clinic, a federally qualified healthcare center, or a community pharmacy). For practice sustainability, it generally requires using as many eligible codes for pharmacist services as are available and appropriate. Although rules and opportunities may differ between practice sites, many also transcend the practice location and are included in the discussion. The codes are summarized in Table 8.1.
Criteria for Incident-to Services
Hospital Outpatient Services
Nonhospital Outpatient Services
Service is provided under the direct supervision of an eligible physician or nonphysician practitioner. Defined as within the suite or office space where the service is performed and immediately available to furnish assistance.
General supervision replaces direct supervision
Established patient: Patient must be an established patient with the eligible provider. Must have an initial face-to-face visit with the provider where the plan of care is established.
Service is an integral, though incidental, part of the eligible provider’s services.
Services are commonly rendered without charge or are included as part of the eligible provider’s bill.
Services are of a type that is commonly furnished and appropriate to be provided in a physician’s offices or clinic.
Service must be medically necessary, authorized (authorized practitioner’s order), and documented.
Authorized provider must provide subsequent services at a frequency that reflects active participation in treating the patient and plan of care.
Financial relationship must exist between the auxiliary personnel and the eligible provider.
Must be an employee, leased employee, or independent contractor
Services provided are within the scope of practice for the auxiliary personnel as dictated by the state practice act.
When pharmacists provide delegated patient care services as auxiliary clinical staff, including pharmacy telehealth practice, a set of rules known as “incident-to” apply for the majority of FFS codes, with some differences based on practice sites that are noted. These rules were created by CMS as a safety mechanism to ensure that the supervising provider is directing the care of the patient, that the delegation of care is appropriate, and that any immediately needed or more complex level of care outside the scope of the ancillary staff is readily available from the supervising provider. As technology has evolved, CMS has relaxed some rules when using available technology advances in communication for certain situations that are noted below.
The incident-to rules must be adhered to when using “incident-to” codes, and they are summarized in Table 8.2. Pharmacists as auxiliary personnel may only provide services to established patients from a referring eligible provider. This rule ensures that the delegating provider has created the plan of care for the patient's medical needs and establishes the medical necessity of the referral. A pharmacist would never be the first provider to see a patient in a practice. The delegating provider may only refer patients for billable services that they would otherwise provide in their practice. If the provider were not delegating the service, they would be responsible for providing the care needed. The supervising provider must continue to actively manage the plan of care as evidenced by documentation and continued visits with the patient. It would be unacceptable for a patient to have seen only the pharmacist for any extended period of time. An example would be a situation where a chronic anticoagulation patient has only seen the pharmacist for a year of care. The auxiliary clinical staff may only provide services that are within their scope of practice as defined by their state's practice act. As state pharmacy practice acts vary in delineating the patient care services a pharmacist may provide, what is billable by supervising providers for pharmacist services will differ throughout the country.
Summary of Billing Codes Available for Pharmacist Services Reimbursement
Billing Code Description
Sites Where Codes May Be Used
“Incident-to Rule” Comments
Annual Wellness Visits (AWV)
Can be done audio/video, NOT audio only
Requires use of GT or 95 modifier
Vital signs can be waived during public health emergency
Chronic Care Management (CCM) and
Complex Chronic Care Management
The codes are intended to be telephonic; however that is not a requirement.
FQHCs have separate codes; see General Care Management
Continuous Glucose Monitoring (CGM)
95249, 95250, 95251
Can be done telephonic with access to data
Diabetes Self-Management Training (DSMT)
Must use audio/video platform or state reason for use of audio only
Requires use of 95 modifier
Requires referral from a Medicare-eligible Part B provider and accreditation from ADA or ACDES
Established Patient Evaluation and Management (E/M) codes
Can be done audio/video, NOT audio only
Requires use of GT or 95 modifier
Pharmacist services may only be billed at 99211
General Care Management
In place of CCM, complex CCM and PCM services in an FQHC
International Normalized Ratio (INR) Monitoring
Medicare Diabetes Prevention Program (MDPP)
G9873-G9879, G9880-G9885, G9890, G9891
First visit still in person; others can be telehealth
Can restart the series at any time
Requires recognition from the CDC’s DPRP
Medication Therapy Management (MTM)
99605, 99606, 99607
Can be done telephonic
Codes not recognized by Medicare
Primary Care Management* (PCM)
G2065, refer to 2022 Physician Fee Schedule for proposed conversion to E/M codes
The codes are intended to be telephonic; however that is not a requirement.
FQHCs have separate codes; see General Care Management
Remote Physiologic Monitoring (RPM)
99453, 99457, 99458
Transitional Care Management (TCM)
Requires physician visit at 7 or 14 days to bill
Supervision of the auxiliary clinic staff is required by the billing provider and differs for certain billing codes and practice sites (see Table 8.2 and the code descriptions below). Certain billing codes require direct supervision, meaning the supervising provider is physically in the suite where the patient care is being provided but does not need to physically be in the visit room. For telehealth pharmacy practice services, direct supervision can be provided virtually, meaning that it is met through immediate accessible audio/video technology. Other billing codes and outpatient services provided and billed under a hospital TIN require general supervision, which is defined as evidence that the supervising provider is directing the plan of care and there is bidirectional sharing and communication of the patient's care plan. For general supervision, there is no requirement of physical accessibility of the supervising provider.
Ancillary clinical staff must be an expense to the billing provider. In the hospital setting, the ancillary staff must be an employee or contracted independent provider. For other settings, the rules are not as specific, stating that the ancillary clinical staff must be an expense to the billing provider through a financial relationship. A practice site may not bill for pharmacist services without reasonable and customary remuneration to the pharmacist for their services.
Hospital or Health-System Billing (“Facility Fee” Billing) Codes: APC 4012 with G-0463
Payment rules for hospital outpatient services are governed by the Hospital Outpatient Prospective Payment System (HOPPS); they differ in payment for the same services provided in independent physician offices and clinics. Facility costs such as electricity and janitorial services are a separate charge from services in the hospital reimbursement structure. In the same manner, facility costs in HOPPS are not woven into the code reimbursement amounts, as it is for the Physician Fee Schedule. When outpatient services are provided and billed under the hospital's TIN, a professional fee is billed by the eligible Medicare provider, and a “facility fee” is paid to the hospital for the facility costs of providing the service to a beneficiary. Pharmacist services in this setting are billed as a facility fee charge incident-to with general supervision by an eligible Medicare Part B provider by the hospital. Similar to how inpatient service payments are grouped, outpatient patient care service payment is grouped together into ambulatory payment classifications (APCs), with the addition of a clinical services HCPC code. Patient care services provided by pharmacists in the hospital outpatient setting are billed under APC code 4012 and HCPC II code G-0463. These codes are subject to “incident-to rules” and as of 2020 require general supervision by the supervising provider.
CPT EVALUATION AND MANAGEMENT (E/M) CODES
Patient care in the ambulatory setting is best represented by the evaluation and management (E/M) codes. These codes describe the level and complexity of medical evaluation and management of a patient by a provider during an ambulatory visit. When utilized for a billable interaction, the work provided should include three major components of care: history, examination, and medical decision making.1 Several codes (CMM, PCM) are exceptions to this rule, in that time spent in the visit determines the code chosen for reimbursement. CMS defines medical decision making as the complexity of establishing a diagnosis and/or selecting a management option.1 Documentation of services provided must demonstrate the required elements of the E/M code being used for billing. Guidance for the element requirements is outlined in the specifications created by the AMA for the CPT codes and in the annual CMS Physician Fee Schedule rulings. The following codes are available E/M codes that may include pharmacist patient care services. All billed codes must be submitted by a supervising provider and meet incident-to rules. As mentioned, supervision requirements and additional details needed for billing can be different for telehealth codes.
Established Patient (99211-99215)
Established patient codes are the main codes used for patient visits in the ambulatory physician office or clinic setting and are recognized by all payers. The codes may also be used in the health system or hospital setting for Medicare billing when ambulatory services are billed under a physician or medical provider group NPI and not the hospital TIN. Hospitals and health systems may choose to incorporate their medical groups and bill established patient codes as a physician group and not under the hospital TIN in lieu of a facility fee. A rationale for doing so allows the medical group to be for profit and the hospital to remain nonprofit. Established patient codes require direct supervision when used as incident-to services.
For incident-to services, an established patient is defined as a patient initially seen by the referring physician within the previous three years for the same problems for which you as the ambulatory pharmacist (i.e., auxiliary clinical staff) will be providing services. The code used to describe the billable interaction is determined by the visit's level of complexity or the time spent with the patient for coordinating care or education. CMS for 2021 is adopting new E/M documentation requirements for new and established patients developed by the AMA. An advantage of the new guidance is that it improves the efficiency of necessary documentation and reduces redundancy.2 A negative for pharmacists is that the AMA document states that incident-to services by auxiliary personnel cannot be billed higher than 99211 and that time-based coding may only be used by providers who can independently bill. Until this 2021 CMS ruling, the level for which services provided by pharmacists as auxiliary personnel should be billed had been unclear, resulting in varied interpretations by both MACs and compliance officers as to whether higher codes than 99211 may be used. In the 2021 PFS, CMS states that although they recognize that other payers may pay pharmacists directly for patient care services, under Medicare, pharmacists are not among the qualified healthcare providers that may furnish services billed at 99212-5. In addition, CMS stated that time-based billing cannot be billed as “incident-to.”3 As of January 1, 2021, pharmacist services billed to Medicare as “incident-to” established patient visits were limited to the 99211 level. Commercial payers and state Medicaid may opt to utilize all code levels for incident-to established patients for delegated pharmacist services. Generally, as Medicare is the gold standard in healthcare reimbursement, other payers tend to follow CMS's rules.
In general, most services provided by pharmacists are eligible for 99211 billing, such as those rendered under collaborative drug therapy management protocols and collaborative practice agreements. The 99211 code may also be billed utilizing audio/video visits via telehealth. These visits generally require the use of a GT (via interactive audio and video telecommunications) or a 95 modifier to show they were completed via telehealth versus in person.
While typical disease management visits such as diabetes and hypertension would be reimbursed under this model, it is always important to check state regulations as well for any exclusions for telehealth. For example, many states have regulations regarding face-to-face requirements for patients receiving opioid or controlled substance prescriptions, but these have traditionally excluded telehealth as a way to complete these visits. In the current COVID-19 public health emergency, many states have waived the in-person requirement, but this highlights the need to ensure that even if the code being billed is covered via telehealth, you are also meeting requirements for the particular service under this code.
Chronic Care Management—CCM (99490, G99439) or Complex Chronic Care Management—Complex CCM (99487, 99489)
CCM and complex CCM are available billing codes for hospitals or health systems’ outpatient services and medical offices.4 These codes are designed for services delegated to auxiliary personnel. Both types of CCM services may be provided under general supervision, which allows the service to be provided at a different site than the supervising provider. Pharmacists may be in a location other than where the supervising provider practices, including pharmacies. Beneficiaries qualify for CCM if they have two or more of any type of chronic condition that will last at least 12 months, or until the patient's death; and the condition places the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. Complex CCM is intended for the category of patients requiring moderate- or high-complexity medical decision making, with evidence of the complexity documented. CCM codes may be non-face-to-face; therefore, services may be provided via any telehealth modality, including phones.
CCM has a set of rules that the healthcare team must adhere to when providing and billing for this service, including the following:
The referring provider's initiating face-to-face patient visit
During the public health emergency, this requirement was waived and can be completed telephonically
24/7 access to team members
Electronic and shared comprehensive care plan and ongoing assessment, as appropriate for the patient
Enhanced continuity with community services
The CCM codes are billed monthly and may only be submitted by one provider per patient. However, services can be provided by multiple clinical staff of the billing provider. The code 99490 is billed for the first 20 minutes of services, with the option for two additional 20-minute units (code G2058) of services if needed per month. Complex CCM is billed with code 99487 for the first 60 minutes of clinical staff time; if an additional 30 minutes is needed, CPT code 99489 is used. For more details, visit CMS's Medical Learning Network for up-to-date guidance material (CMS Chronic Care Management).
PCM follows CCM rules and regulations. Unlike CCM, PCM is intended for a single high-risk disease or complex condition expected to last at least 3 months to 1 year where the condition may have led to a recent hospitalization and/or may have placed the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. PCM is available for physician offices or clinics. CMS intends PCM to be used for a complex condition that requires management by a more specialized practitioner than primary care. The specialist would stabilize the condition and then return care to primary care. CMS, however, places no restrictions on which specialty may use the codes and acknowledges that primary care may also provide the service and use the code.
PCM may be billed by more than one practitioner. However, the same practitioner cannot bill CCM with PCM. CMS created two initial codes for PCM. G2064 is to be used when PCM services are provided by an eligible Medicare provider, and G2065 is to be used when clinical staff (i.e., pharmacists) under incident-to rules and general supervision provide the service. Like CCM, PCM may be provided under general supervision.
Transitional Care Management—TCM (99495, 99496)
Like CCM, TCM codes are available for payment in hospitals or health systems, medical offices, and federally qualified health centers.5 This Medicare benefit is intended to reduce 30-day rehospitalization by reimbursing for care management and care coordination after a discharge from an institution (inpatient hospital, rehabilitation and psychiatric institutions, observational inpatient stays of less than 48 hours, skilled nursing facility) to the community. The billable services have two components: a telephonic portion that permits auxiliary clinical staff to perform a set of services under incident-to rules and general supervision; and a face-to-face visit that must be provided by a Medicare-eligible billing provider.
The telephonic component requires interactive communication with the patient or caregiver within two business days of discharge. This may be done by the billing provider or licensed clinical staff within their state scope of practice under incident-to rules and general supervision. Telephone, email, or text messaging are all acceptable for this interaction. CMS does not specify that the required elements of this visit other than care management and coordination should occur.
The face-to-face component must be furnished by the billing provider either within 7 days for a patient requiring high-complexity medical decision making using the 99496 code or within 14 days for less complex patients using the 99495 code. As with CCM, only one provider may bill for TCM services, and the charge may only be used once within a 30-day period regardless of the number of admissions or discharges during that period. More details on utilizing this code may be found in the CMS MLN Newsletter for TCM services.
RPM codes are available for hospital, health-system outpatient and physician offices, or clinics.2 RPM codes pay for the collection and analysis of patient physiologic data collected through a remote device, where the device is used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition. The device (e.g., weight scales, blood pressure monitors, pulse oximeters) must meet the Food and Drug Administration (FDA) definition of a medical device and should automatically upload patient physiologic data through digital means and not be data that are patient self-recorded and/or self-reported. Services may only be billed for established patients.
Auxiliary clinical staff (e.g., pharmacists) may provide setup and monitoring of RPM services incident-to a Medicare-qualified provider under general supervision. The initial setup and patient education on use of the equipment may be provided and billed once using code 99453. Monitoring of daily transmissions or programmed alerts received from the patient's device may be billed using code 99454 submitted every 30 days and must have at least 16 days of data. Auxiliary clinical staff may provide management of therapy related to remote physiologic monitoring through interactive communication with the patient or their caregiver for at least 20 minutes during the calendar month to bill code 99457. An add-on code of 99458 is available for each additional 20 minutes as needed. Interactive communication is defined as real-time synchronous two-way audio interaction (i.e., phone) that is capable of being enhanced with video or other kinds of data transmission. It should be noted that the physiologic data, billed as code 99091, may only be interpreted by an eligible Medicare provider.
Chronic or Complex Management (CCM), Remote Physiologic Monitoring (RPM), Principal Care Management (PCM), and the pharmacist's role in Transitional Care Management (TCM) have always been allowed via telephonic means. With primary care and pharmacist-specific revenue decreasing with fewer in-person visits, renewed interest and understanding of CCM, RPM, and PCM have occurred. No additional regulations beyond those discussed previously are required to utilize these through telehealth means as these are not considered telehealth codes.
CGM is available for payment in hospital/health-system ambulatory care practices and physician offices and requires direct supervision incident-to an eligible Medicare provider. CGM is a glucose monitoring modality available to patients with diabetes who require frequent testing, dosing of their insulin, and adjustment of their therapeutic regimen. Because CMS has deferred CGM regulations to the MACs, variation in requirements may exist between MACs, and MAC regulations should be reviewed prior to utilizing the codes.
There are two types of CGMs: (1) one for personal use where interstitial glucose level data are presented directly to the patient for real-time self-management and (2) one for professional-use CGMs where data are transmitted for interpretation by a healthcare provider. Personal-use CGMs may be limited due to their cost. Most payers provide coverage for professional-use CGMs. For personal-use CGMs, CPT code 95249 may be billed once for education and training of a personal-use CGM. For professional-use CGMs, CPT code 95250 may be billed monthly for CGM sensor placement or removal and supplying equipment, calibration, printout of recording, and patient training. CPT code 95251 may be billed monthly for analysis, interpretation, and reporting of at least 72 hours of glucose data for either personal- or professional-CGM use.
Current regulations do not require the face-to-face component in order to bill for CGM services outside of device placement. Similarly, local coverage determinations for requirements for obtaining a CGM device have been waived during the public health emergency, allowing greater access for patients. Providers can then utilize online portals or patient-provided uploads for CGM interpretation and glucose management.
International Normalized Ratio Monitoring—INR (93792, 93793)
INR monitoring codes are available for hospital/health-system outpatient and physician office billing for clinical staff under direct supervision by a physician or other qualified healthcare professional. CPT code 93792 is for billing patients or caregiver training for initiation of home INR monitoring; it includes use and care of the INR monitor, obtaining a blood sample, instructions for reporting home INR test results, and documentation of the patient's or caregiver's ability to perform testing and report results. CPT code 93793 is for billing review and interpretation or an INR and anticoagulant management for a patient taking warfarin obtained in the home, office, or lab. It therefore includes telephonic monitoring. Documentation should include patient instructions, dosage adjustment (as needed), and scheduling of additional test(s).6 The reimbursement rate for this code is lower than the established patient code 99211 and thus is less commonly used.
Medicare does not recognize MTM codes for direct reimbursement to a provider in any of its benefit plans. The MTM codes may be available for reimbursement under state Medicaid, from PDPs in executing the Medicare Part D MTM requirements and some commercial payers. MTM codes are time based, with code 99605 used for the initial 15 minutes of a face-to-face visit with a new patient. Code 99606 bills for the initial 15 minutes of a face-to-face visit with an established patient, and 99607, as an add-on code for each additional 15 minutes for either a new or an established patient.
While CPT definition of MTM codes is face-to-face, these codes have been utilized via telephonic interactions for several years, and current telehealth regulatory changes did not affect the payment or delivery of these codes. Current reimbursement for these codes remains through Medicare Part D or other direct contracted plans.
HCPCS LEVEL II G CODES
Annual Wellness Visits—AWV (G0438, G0439)
AWV codes are available for payment in hospitals or health systems, medical offices, and federally qualified healthcare centers. The AWV is a benefit meant to focus on wellness and disease prevention, and thus, like other preventive services from CMS, it does not have an associated co-pay. Three visit types are included in the benefit, of which only two may be provided by ancillary licensed clinical staff under direct supervision of the eligible billing provider. The first service under the AWV benefit is the IPPE—the initial preventive physical examination (G0402 code)—that may only be provided by an eligible Medicare Part B provider. This visit is also referred to as the “Welcome to Medicare” visit. The initial Annual Wellness Visit (G0438) is conducted one year later; it is billed only once and may be provided by ancillary clinical staff. Thereafter, an AWV with clinical staff may occur each year and is billed under code G0439. Each code has an associated set of screenings and services that must be provided to bill the code. Details for the AWV requirements may be found on the CMS Medical Learning Network website.7
AWVs are also allowed to be conducted via audio/video two-way communication with the patient; audio only visits are not considered billable. Similar to established patient codes, a GT or 95 modifier is required when submitting claims. All elements of the AWV, whether initial or subsequent, must be met with the potential exception of the vitals component. Patients can self-report height, weight, and blood pressure if able. Under current circumstances, it is also acceptable to waive the vitals component with the additional documentation of “unable to obtain due to COVID-19 public health emergency.”
Although pharmacists are unable to perform the initial preventive physical exam (IPPE-G0402), it is important to note that this exam is also not allowable via telehealth.
General Care Management for FQHCs Only (G0511)
FQHCs are eligible to bill for CCM, complex CCM, and PCM services. For FQHCs the codes 99490, 99487, and G2065 are collapsed into one code, G0511, and submitted by the FQHC when any of these services are provided.
DSMT is available for billing by any provider in any setting, including pharmacists practicing within their state scope of practice. Requirements are that the service must be initiated by an order from a Medicare-Qualified Provider who is managing the patient's diabetes stating there is a medical need for DSMT, and the DSMT program must have accreditation from either the Association of Diabetes Care and Education Specialists (ADCES) or the American Diabetes Association (ADA). A list of diabetes topics must be included in the curriculum, and the education must be provided within a set education visit timeframe and frequency over a 12-month period. The education may be provided individually (G0108) or to a group of patients with diabetes (G0109), with each method having its own rules for length and frequency of instruction. Additional details on DSMT regulations may be found on the Government Publication Office website.8
Accredited DSMT programs eligible to directly bill Medicare, including pharmacists providing services within these programs, can provide services via telehealth in any healthcare setting. Regulations specify that audio/video communication should be used if at all possible. In addition, if audio only is utilized for services, reason for use must be clearly documented. Use of location modifier 95 is also required for use during these visits. Programs originating out of an outpatient hospital site may still bill for services under the NPI and TIN. Visits can occur via telehealth for both new and established patients.
MDPP is a service based on structured and evidence-based interventions designed to prevent the onset of type 2 diabetes in Medicare beneficiaries identified with prediabetes. MDPP services are provided by a “coach” who must have an NPI number and must have attained recognition through the Diabetes Prevention Recognition Program (DPRP) from the CDC. The DPRP entails training, reviewing, and completing the CDC's standards and procedure requirements.9 Providers of this service are from a wide range of background practice sites that include health clubs, health systems, public health organizations, physician offices, and pharmacies. MDPP includes a set of core sessions over the first 6 months, followed by ongoing maintenance sessions for an additional 18 months. The list of codes reflects the different sessions and required documentation. MDPP providers submit claims through the usual Medicare Part B processes, with payments made based on beneficiary attendance and weight loss of 5% from baseline for the first 6 months and 9% from baseline at the completion of the program.
Providers of MDPP as of March 1, 2020 may provide services virtually. Of note, certain requirements, such as the first session requiring in-person attendance, are still in effect. While some in-person requirements remain, participants whose sessions have been disrupted by the pandemic are now able to start a program over or resume it at a later date. Previously, this had been a once in a lifetime benefit.
SUMMARY OF FEE-FOR-SERVICE BILLING
Presented in this chapter is a small fraction of the available codes used by providers for the services and procedures presently in healthcare delivery. The codes discussed are those where CMS specifically states that services may be delegated to auxiliary personnel or clinical staff to perform under supervision; or codes that CMS allows pharmacists to bill directly as providers. Other existing codes may be used by eligible Medicare providers where the provider is conducting the visit and the pharmacist is participating as clinical staff. These codes were not reviewed as they are billing mainly for the eligible provider's service. Clinical staff is considered a participant. In such situations, the billing provider must adhere to the code requirements in providing the service in conjunction with their staff. Billing is key for financial sustainability. The available codes have variable reimbursement rates that are impacted by location. To determine the current rate of payment for a billing code from Medicare to physician offices (based on location), it is best to access the Physician Fee Schedule Lookup tool: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup. To obtain payment information for Medicare hospital outpatient, FQHCs, commercial payers, and state Medicaid, it is more challenging and best to work with your compliance officer for this information.
SUMMARY OF TELEHEALTH PHARMACY PRACTICE BILLING TOOLS
This information can be complex, and pharmacists who are delivering telehealth services must be kept informed of, and keep up-to-date with, the ever-evolving details. Upon becoming familiar with these concepts, pharmacists must then be prepared to implement and operationalize telehealth and billing for telehealth pharmacy practice services, which includes ongoing quality control. Many tools need to be included in any pharmacy practice's toolkit to build a practice that optimizes telehealth for billing and reimbursement.
Several key components are important to ensure that billing and regulatory requirements are satisfied, while continuing to guarantee practice efficiency. These should be considered in addition to the concepts discussed in Section 2: Telehealth Pharmacy Practice Workflows. Recognizing supervision and audio/video platform requirements, identifying support and billing staff, and customizing the implementation of telehealth to the specific practice site are among the important considerations. Further, understanding state-specific billing rules and available opportunities is vital to guide development of the telehealth practice.
SUPERVISION OF PHARMACIST TELEHEALTH BILLING
As described previously, a variety of methods are available to carry out telehealth pharmacy practice patient care services, including live video, store-and-forward, remote patient monitoring, and care via email, telephone, and fax. Live video is the most predominantly reimbursed form of telehealth across the nation. Every state offers some type of live video reimbursement in its Medicaid program. There is variability, however, in how the reimbursement is done and for what services (e.g., behavioral health only in New Jersey vs. a wide variety of specialties in California). There are limitations on the types of services that can be delivered and reimbursed via live video, as well as types of providers. The “originating site” refers to the location of the patient, and some states have restrictions on this too.10 Depending on the service provided, there may also be requirements for pharmacist supervision. Failure to meet these supervision requirements can result in loss of payment in the event of auditing. Pharmacists should ask themselves, What needs to be in place to ensure that supervision requirements are met? The answer will depend on the type of telehealth delivery method as well as the specific service being provided. It is important to determine whether direct or general supervision is required for the service being provided, summarized in Tables 8.1 and 8.2. The COVID-19 pandemic led CMS to allow for a provision that virtual, real-time audio/video technology may be used to satisfy the requirement for direct supervision.11 By definition, general supervision does not require physical accessibility to the supervising provider, so telehealth methods are therefore an acceptable means of providing care.
To satisfy direct supervision via telehealth, it is important for pharmacists to develop a plan with their physician colleagues. This plan may involve changes to workflows to allow for a method for the physician to be accessible when needed, and also ensure that contact information is available for both the pharmacist and physician colleagues, along with up-to-date work schedules.
Audio/Video Platform Considerations
When planning for implementation of telehealth pharmacy practice services, privacy and security standards must be considered, and ensuring that HIPAA rules are followed is a necessity. The Department of Health and Human Services Office for Civil Rights (OCR) states that healthcare providers must ensure that telehealth is conducted privately. This generally means that the service is delivered by the healthcare professional in a clinic or office connected to a patient in their home or at another site. OCR specifies that patients should not participate in telehealth pharmacy practice visits in a public setting unless consent is provided by the patient or “exigent” circumstances exist. If it is not possible to provide telehealth pharmacy practice services in a private setting, OCR recommends that healthcare professionals continue to abide by HIPAA guidelines in order to minimize any disclosure of protected health information (PHI). Examples can include using lowered voices, avoiding use of a speakerphone, or recommending that the patients position themselves in a location at a reasonable distance from others, especially when discussing PHI.12
When delivering telehealth pharmacy practice via live video, the platform used must be “nonpublic facing.” This means that the platform “allows only the intended parties to participate in the communication.”13 Acceptable non-public-facing platforms include Webex, Doximity, Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, Zoom, or Skype. These platforms typically utilize end-to-end encryption, which allows only an individual and the person with whom the individual is communicating to see and hear what is communicated. Unacceptable platforms that would not be considered nonpublic facing would be those that allow wide access to communication or public, such as a “livestreaming” service. Examples include TikTok, Facebook Live, Twitch, or any public online chat room.
Support Staff Considerations
Meeting with your practice site's billing and/or coding staff (or meeting with your local clinic's staff if practicing in a community pharmacy) can prove vital to ensure that all required elements and information are being properly documented for any telehealth services, as well as to confirm that the appropriate billing codes and modifiers are being submitted. Leveraging registration and nursing staff, pharmacy technicians, and learners can also enhance efficiency when delivering services via telehealth. Examples can include utilizing registration staff to help schedule video visits and provide appropriate login information for patients, nursing staff to start up video visits and collect patient intake information, including vitals (if applicable) and alert you when the patient is ready to be seen (“virtual rooming”), and using pharmacy technicians and learners to perform appropriate delegated tasks such as medication reconciliation.
Monitoring Telehealth Billing Quality
In addition to meeting with billing staff to prepare for compliance with telehealth billing regulations, it is also important to monitor the quality of the telehealth billing process. This can be done by tracking reimbursement through the billing reports generated and by meeting regularly with billing and financial administration to identify problems with billing as well as new opportunities. It is also important to consider continuous review of the cost of telehealth technology, including the platforms used to deliver video visits.
Center for Medicare and Medicaid Services. Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID-19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID-19. Federal Register, December 28, 2020.
Centers for Medicare and Medicaid Services. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Federal Register. 2017. https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. Accessed May 13, 2021.)| false
Agency for Healthcare Research and Quality. Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews. June 2016. Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews (ahrq.gov).