CMS Clarifies “Incident to” Relating to Pharmacist Services

by | Last updated May 17, 2023 | Published on Aug 6, 2014 | Healthcare News

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According to the communication between the American Academy of Family Physicians (AAFP) and the Centers for Medicare & Medicaid Services (CMS), Physicians may bill for pharmacist services as part of the “incident to” services provided to Medicare patients. Medical billing regulations are often complex, even those applicable to family physicians.

Physicians frequently rely on the incident-to method to obtain reimbursement for the work of nurse practitioners and physician assistants. Pharmacists often work directly with patients at both large and small integrated health systems. Their duties range from providing medication reconciliation and patient education to administrating immunizations and tests such as spirometry. When billing for these services is concerned, questions arise as to whether incident to rules apply to situations in which a pharmacist employed by the physician’s practice also engages with patients.

To clarify this, the AAFP (American Academy of Family Physicians) sent a letter to the administrator of the Centers for Medicare & Medicaid Services (CMS), asking whether pharmacists qualified for incident-to billing just as much as other clinical team members, particularly because their face-to-face encounters with patients had all the trappings of an office visit. The response from CMS was that the physicians could indeed bill Medicare for a pharmacist’s work under their own provider number.

CMS also mentioned that:

  • The services of supporting personnel are eligible for “incident-to” only if they lie within the scope of their state license.
  • Medication management services, covered by billing codes 99605 to 99607, are not covered in Medicare’s Part B program, which includes physician reimbursement. However, a beneficiary’s Medicare Advantage plan or Part D medication plan can pay for medication management, and incident-to requirements do not apply.

AAFP officials have also recommended that if an established patient had an office visit with a pharmacist without seeing his or her supervising physician, the practice would probably be limited to the lowest paying CPT code for such an evaluation and management (E/M) service – 99211. However, an office visit with a physician that included time spent with a pharmacist may entitle the physician to a higher E/M code.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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