reimbursement opportunities for clinical pharmacists...

Michigan Pharmacist Transforming Care & Quality

Reimbursement Opportunities for Clinical Pharmacists (1/10/17)Hae Mi Choe, PharmDMPTCQ Program Director


Care Management Billing Codes– PCMH Designation: BCBSM (required), Priority Health (not required)

– No member co-pays or deductibles (including high-deductible plans)

– Face-to-Face: G9002 BCBSM (Commercial and Medicare Advantage): Quantity Billing

– If the total cumulative time with the patient adds up to: o 1 to 45 minutes, report a quantity of one; 46 to 75 minutes, report a

quantity of two; 76 to 105 minutes, report a quantity of three; 106 to 135 minutes, report a quantity of four

Priority Health (Commercial and Medicare Advantage): No Quantity Billing– 1 time per date of service when billed under the same provider

group– Used for disease management services - NOT for CMR


Care Management Billing Codes (cont’d)

– Telephone Services: 98966 for 5-10 minutes; 98967 for 11-20 minutes; 98968 for 21-30 minutes

– Team Conferences (G9007): Meeting between at least the PCP and the care manager to formally discuss a patient’s care plan. Can be billed once per day per patient regardless of time spent. BCBSM Commercial (June 2016):

– Face-to-face meetings, telephone calls or secured video conferencing

BCBSM Advantage (August 2014)– Face-to-face meeting

Priority Health– Scheduled care team meetings


Care Management Codes Reimbursement

Codes Description

BCBSMCommercial/Advantage

(updated 2016)

Priority HealthCommercial/Advantage

(updated 2017*)

98966Telephone assessment,5-10 minutes $15.21 $17.00



G9002Coordinated care fee, individual face-to-face visit $59.28 $76.88*

G9007Coordinated care fee, team conference $30.09 $39.13*

Note: Pharmacist can bill G9001 ($154.19*) for Priority Health patients. N/A for BCBSM patients.


BCBSM: PDCM VBR 5% Uplift

BCBSM commercial PDCM-eligible patients. Practice must be a PCMH.

For uplift starting 7/1/2017, at least one paid claim for 2% of eligible members in 2016.

For uplift starting 7/1/2018, at least two paid claim for 3% of eligible members in 2017.

Pharmacist can serve as the qualifying care manager for the uplift– Practice must have “access” to a lead care manager through PO

to obtain support as needed– Pharmacist must complete CMRC online PDCM training and 8

hours of clinical educational webinars yearly thereafter


Priority Health PCP Incentive Program

PCMH designation not required Two billed care management claims per member for 3% of unique

members in 2017 $2.75 PM/PM (Commercial and Medicare Advantage)

$1.25 PM/PM (Medicaid) Pharmacist can serve as the care manager for the practice

– Must complete approved care management training in the first year as the care manager and 8 hours of continuing education yearly thereafter


Care Management TrainingClinic Example #1:We have a nurse care manager who works at our practice. Her name is listed in the attestation form for care management incentive programs. Also, we have a pharmacist providing care at our practice.

Question #1: Will pharmacist be required to take initial training on care management and 8 hours of CE yearly thereafter?

BCBSM: NoPriority Health: Yes

Clinic Example #2:We have a pharmacist who works at our practice. Her name is listed in the attestation form for care management incentive programs. To meet BCBSM requirement, we have access to a lead care manager from whom we can obtain support as needed when managing complex patients.

Question #1: Will pharmacist be required to take initial training on care management and 8 hours of CE yearly thereafter?

BCBSM: Yes. Pharmacist MUST take CMRC PDCM online course as the initial training.Priority Health: Yes


Med Reconciliation Post-Discharge Code 1111F (billed on professional claim): medication

reconciliation within 30 days of a hospital discharge BCBSM Commercial: $35 (as of January 1, 2017) BCBSM Advantage: $10 (as of July 11, 2016) No member cost sharing Can be billed with face-to-face office visit, telephone CPT

code, or alone BUT not with Transitions of Care codes (99495, 99496)

Outpatient medical record must include: – hospital discharge date – date the medication reconciliation was completed – documentation indicating that the patient’s current list of medications was

reconciled against the hospital discharge list of medications


Priority Health/OutcomesMTMComprehensive Medication Review

– Medicare Advantage Plan: 4+ chronic medications, 3+ chronic conditions, and incur the CMS defined annual drug spend for CMR. Pharmacist can identify members outside of this criteria and “add” them for a CMR service. Must call OutcomesMTM to add a patient (3-day turn around).

– Commercial Plan/Medicaid: 4+ chronic medications. Pharmacist can identify members outside of this criteria and “add” them for a CMR service. There is an option to “add patient” in the Connect platform. No need to call to OutcomesMTM.


Priority Health/OutcomesMTM

CMR is generally provided once a year. However, per pharmacist’s discretion, more than 1 CMR can be reimbursed. Need to call OutcomesMTM for additional CMRs.

OutcomesMTM allows for either face to face or telephonic CMR. Virtual/telehealth visits = “in person” visit.

Standardized “Take Away” medication list must be documented and generated through OutcomesMTM Platform.

Contact Shane Hallengren at OutcomesMTM: [email protected]

mailto:[email protected]


Reimbursement

$30 year-end incentive payment is available for all members enrolled in the adherence monitoring service if 1) the pharmacist enrolls the patient, AND 2) the pharmacist completes all quarterly check-in’s with the patient, AND 3) the patient demonstrates a PDC of ≥ 80% at the end of the calendar year.

Comprehensive medication review $75OTC consultation $10Patient adherence consultation $20Patient education and monitoring $10Prescriber consultation $10Prescriber consultation – rx validation $10Patient refusal $2Prescriber refusal $2


References Provider Delivered Care Management Payment Policy and

Billing Guidelines for Blue Cross Blue Shield of Michigan Medicare Advantage PPO (August 2014)http://micmrc.org/system/files/BCBSM%20PDCM%20Payment%20Policy%20and%20Billing%20Guidelines-Medicare%20Advantage%20Aug%202014%20v1.pdf

Provider Delivered Care Management Payment Policy and Billing Guidelines for Blue Cross Blue Shield of Michigan Commercial (June 2016)https://mipctdemo.files.wordpress.com/2015/05/bcbsm-pdcm_billing_guidelines-june-2016-v3-2.pdf

Priority Health Care Management Billinghttp://www.priorityhealth.com/provider/manual/billing-and-payment/services/care-management-codes

http://micmrc.org/system/files/BCBSM%20PDCM%20Payment%20Policy%20and%20Billing%20Guidelines-Medicare%20Advantage%20Aug%202014%20v1.pdf

https://mipctdemo.files.wordpress.com/2015/05/bcbsm-pdcm_billing_guidelines-june-2016-v3-2.pdf


Medicare Billing We are not able to advise you on Medicare billing practices

due to nuances in financial structure

However, the following slides contain information regarding “incident to” billing, which your practice may want to explore further


“Incident to” Billing


Medicare “incident to” Billinghttps://petitions.whitehouse.gov/response/pharmacists-and-social-security-act Official Centers for Medicare & Medicaid Services Response toRecognize pharmacists as health care providers! This response was published on January 17, 2014.

Pharmacists and the Social Security Act By Jonathan Blum Thank you for your petition on recognizing pharmacists as health care providers under the Social Security Act. As you noted, pharmacists are not recognized in the Social Security Act as health care providers who are authorized to bill and receive payment for their services from Medicare. To do so would require a change to the statute by Congress. But we recognize and value the trusted role that pharmacists play in the community, and their importance to patient care -- in particular to Medicare beneficiaries who need prescription medications. The term "provider" is defined in Medicare regulations at 42 C.F.R, §400.202 and includes hospitals, skilled nursing facilities, and home health agencies. That term does not include pharmacists. Moreover, the Medicare law specifically authorizes the health care providers who can bill and receive payment from Medicare. For instance, section 1861(r) of the Social Security Act defines "physicians" under the Medicare program. This definition includes, with various restrictions and exceptions, doctors of medicine and osteopathy, doctors of dental surgery and dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors. The statute also authorizes several specific non-physician practitioners including nurse practitioners, clinical nurse specialists, physician assistants, nurse midwives, clinical psychologists, and physical therapists to bill and receive payment from Medicare for their professional services that fall within their State scope of practice. So while pharmacists are not recognized as "providers" who are authorized to bill and receive payment for their services from Medicare, they can receive payment for their services when furnished to Medicare beneficiaries in certain circumstances. For example, pharmacists can receive payment for furnishing services "incident to" the services of a physician or non-physician practitioner. The requirements under the "incident to" provision must be met, including the supervision requirements. The physician or non-physician practitioner who bills for the "incident to" services that the pharmacist furnished would receive payment from Medicare, and the pharmacist would receive payment from the physician or non-physician practitioner based on the agreement established by the parties involved. Pharmacists can also be paid under Part D by Medicare prescription drug plans to dispense prescription drugs as well as to provide medication therapy management services to patients to identify problems and perform medication reconciliation. Please visit CMS.gov for additional information. Jonathan Blum is the Principal Deputy Administrator at the Centers for Medicare & Medicaid Services.


Additional Medicare Resources Hospital-based Clinic – Pharmacist “incident to” billing

– Medicare Benefit Policy Manual – Chapter 6, 20.5.2

Office Based Clinic – 99211 billing– Medicare Claims Processing Manual – Chapter 12, 30.6.4

“Incident to” billing information– Medicare Benefit Policy Manual – Chapter 15, 60.1 and 60.3

“Incident to” Services – Documentation and Correct Billing

CMS Chronic Care Management Serviceshttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

CMS Transitional Care Management Serviceshttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

reimbursement opportunities for clinical pharmacists...

Documents