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Navigating Billing for Pharmacy Services

November 19, 2020

Integrating pharmacists into oncology care delivery models has shown to improve outcomes1 for patients and boost the financial stability of cancer programs and practices. But billing for pharmacy services can be onerous and complicated. In the latest installment of an ACCC webinar series marking American Pharmacists Month, experts discussed how to bill for pharmacists' services in chemotherapy management to accurately reflect the increasing role of pharmacists in oncology and enable those pharmacists to be adequately compensated for the services they provide.

Sandra Leal, PharmD, MPH, FAPhA, CDCES, executive vice president of theHealth Plans and Payers Business Unit for SinfoniaRx at Tabula Rasa Healthcare, and Bhavesh Shah, RPH, BCOP, senior director of specialty and hematology/oncology pharmacy at Boston Medical Center, joined moderator John Valgus, PharmD, MHA, BCOP, assistant director of the department of pharmacy at the University of North Carolina (UNC) Medical Center, on the expert panel.

Impact on Care

Pharmacists are integral to the patient-centered model of care at UNC, Dr. Valgus said, where its Comprehensive Oral Chemotherapy Program is depicted as a triad of three connected points--the clinical pharmacist practitioner, specialty pharmacy services, and the medical doctor--surrounding the patient to ensure the optimal benefit of chemotherapy.

In a study of the impact of pharmacist services on patient care, a leukemia pharmacist at UNC measured the impact of pharmacist intervention on patients with chronic myelogenous leukemia and measured the molecular response in those patients. He found that pharmacist intervention increased patient medication adherence from 52 percent to 74 percent. In addition, 92 percent of patients in the study were adherent to medication regimens, and they saw an improvement in response rates as a result.1

Navigating Billing Codes

Although the benefit of pharmacist intervention is clear, billing for pharmacist services has always been a challenge. At Tabula Rasa Healthcare, Dr. Leal works with the Health Plan and Payers Group to determine how best to use billing codes to account for the value-based care that pharmacists provide and thus justify having full-time pharmacists on staff.

“When we look at how to leverage current billing codes, we look at what’s already been done, and then at what’s coming down from CMS to determine what opportunities are presented there,” said Dr. Leal.

Many pharmacists have traditionally used the “incident to” model for reimbursement of their services. In this model, physicians bill for pharmacist services incident to their requests, rather than the pharmacist billing directly for their services under their own national provider identifier. Dr. Leal, who also serves as president-elect of the American Pharmacists Association (APhA), noted there has been some recent pushback on incident to billing, and she advocates for pharmacists having their own independent provider status. This would enable pharmacists to be more accurately compensated for the level of service they provide at the request of physicians.

Other codes that pharmacists have used to bill for their services include transitional care management codes, chronic care management codes, annual wellness visit codes, and diabetes self-management training (DSMT) codes. The pandemic has had some effect on the way pharmacists have been able to bill for their services. “With COVID, pharmacists were recognized to be able to deliver DSMT through telehealth and be recognized for that,” Dr. Leal said. “That’s very new and something that wasn’t approved before.”

Dr. Leal recommends reviewing the practice site-specific billing codes that are published by Pharmacy Today and are available online. Different practice settings have implications on what codes can be used by pharmacists, and understanding them can help pharmacists more accurately account for their services. Medicaid-specific codes within each state may also be used to account for the work of pharmacists. Although rules vary among states, much of what applies at federal-level rules also applies at the state level. Some states may have specific recognition or codes that enable pharmacists to bill at a higher level than Medicare codes.

Outside of coding for their services, there are several other mechanisms through which pharmacists can be compensated, including value-based contracting, direct patient payment models, drug discount programs, and commercial health payer billing methodologies. “Sometimes commercial health payers will contract with you to provide a certain intervention that might not be recognized by Medicaid or Medicare,” Dr. Leal said. “Looking at those direct value opportunities, a commercial payer might have a specific group or a population that they’re having a challenge with.”

Boston Medical Center

The limitations and complexities of pharmacy billing propelled Boston Medical Center to invest in finding a better way to bill for services in their setting. “Many codes that are out there have a lot of limitations,” Dr. Shah said. “For example, with chronic care management, you can only bill for it once a month per patient, so if a patient is seen more than once per month, you can’t get paid for it.”

The pharmacy team at Boston Medical Center worked with leadership and the finance department to create billing criteria that was customized to a pharmacist and easy to use. The criteria they developed is tied to the number of medications a patient is taking, combined with the level of complexity. For example, if a patient has multiple chronic diseases, the billing criteria level would increase.

The model was built into the medical center’s billing system, which enables the monitoring of the work of individual pharmacists to determine how much revenue they are generating. The compliance department conducts random audits to ensure the system is working as intended. “It pushed pharmacists to function as providers, because now they’re actually billing for each visit and each patient they’re seeing,” Dr. Shah said. This pharmacy billing and tracking model enables Boston Medical Center’s hematology/oncology pharmacy to determine how much revenue pharmacists are bringing in, and thus justify requests for additional full-time employees.

As the COVID-19 pandemic has illustrated, an evolving healthcare landscape demands new strategies and resources to bill for services. “When you’re thinking about future growth of pharmacy resources, it’s important to be able to tie the activity of current pharmacists to revenue that is coming in for your institution or from your practice,” Dr. Valgus said. “It’s also important to establish a role for pharmacy’s impact on the overall cancer program’s bottom line.”

The recorded webinar can be viewed upon registering for ACCC’s American Pharmacists Month webinar series. Other recorded webinars that can be viewed on demand include Closing the Oncology Research Gap, Pharmacy Metrics for Off-Label Treatment, and Pharmacists and Older Adults with Cancer: Effective Practices.

This webinar series is being offered through the ACCC Oncology Pharmacy Education Network (OPEN), established in 2004 to bring together education, resources, and peer-to-peer networking to help pharmacy professionals navigate the accelerating course of change in oncology—clinically, operationally, fiscally, and programmatically. ACCC thanks Merck & Co. for their financial support of the Oncology Pharmacy Education Network.


  1. Hughes TP, et al. Early molecular response predicts outcomes in patients with chronic myeloid leukemia in chronic phase treated with frontline nilotinib or imatinib. Blood. 2014;123(9):1353-60.



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