Question: Can a pharmacist bill a 99213 or 99214 based on time, incident to a physician?
Answer: No.
In some medical groups, pharmacists are part of the care team, working with patients on medication management. The pharmacist provides education to the patient and family. Some patients have complex medication regimens, and pharmacists work with patients to increase understanding, compliance, and improve patient outcomes. The difficulty comes with payment. If you’re in a non-facility setting such as place of service 11 (office) the pharmacist can be billed incident to a physician or non-physician practitioner (NPP) in the same way as an RN or MA can. The difficulty is the level of service in the question.
Let’s briefly review the incident to rules.
- The physician or NPP must have seen the patient at a prior visit and established a plan of care.
- The service of the pharmacist, which is being provided incident to, must be an integral part of the patient’s treatment.
- The physician or NPP or their same specialty partner must be in the suite of offices when the service is performed or must be available through real-time, audio/visual telecommunication.
- The physician or NPP who initiated the service must stay involved with the patient.
- It is a non-facility setting.
How can medication management, described above and performed by a pharmacist, be billed? Using CPT code 99211. You may not bill a higher level of E/M service no matter how much time the pharmacist spends.
CMS addressed this definitively in the 2021 Physician Fee Schedule Final Rule in a section labeled “Pharmacists Providing Services Incident To Physicians’ Services.” They spend some time in the section describing the definitions of physicians and other qualified healthcare professionals (QHP), the terminology that the AMA uses.
CMS reiterates that pharmacists fall within the regulatory definition of auxiliary personnel, and note that their term “auxiliary personnel” could include staff that have clinical roles and staff that don’t. CMS quotes CPT definitions. “A physician or other qualified health care professional as an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional services.” Clinical staff may assist in the performance of the services but don’t report those services themselves. That is, clinical staff are not qualified by licensure to report E/M services independently.
CMS notes there is no statutory benefit that would allow pharmacists to enroll, bill for and receive payments directly.
“As such, pharmacists are not among the physicians and QHPs that can furnish and bill for the 2021office/outpatient E/M visit codes, because levels two through five are by definition only performed and directly reported by physicians or QHPs. For example, when time is used to select visit level, only the time of the physician or QHP is counted. By definition, these codes cannot be furnished and billed as “incident to” services; therefore, they cannot be used to report services consisting of time spent solely by a pharmacist working “incident to” the services of a billing physician. We also note that services furnished directly by pharmacists are listed in a separate section of the CPT Codebook that includes codes describing Medication Therapy Management Services.”[1]
In plain English, CMS is saying:
- Pharmacists may not use E/M code levels two through five
- There are medication therapy management codes in the CPT book, but these are not covered by Medicare.
- Report only 99211 for pharmacists performing medication management in a physician office, POS 11.
[1] 2021 Final MPFS: https://www.federalregister.gov/d/2020-26815/p-1012