The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.

Carol Ott, PharmD, BCPP
Clinical Professor of Pharmacy Practice, Purdue University
Clinical Pharmacy Specialist, Eskenazi Health, Indianapolis, IN
Psychiatry and Gender Health

Carol Ott, PharmD, BCPP, is a Clinical Professor of Pharmacy Practice in the Purdue University College of Pharmacy and a Clinical Pharmacy Specialist in Psychiatry and Gender Health at Eskenazi Health and the Sandra Eskenazi Mental Health Center in Indianapolis. Dr. Ott is a member of the Indiana Medicaid Drug Utilization Review Board, where she has served as the Chair and Vice-Chair, and is a member of the Mental Health Quality Advisory Committee and Psychotropic Medication Advisory Committee for Indiana Medicaid. She serves as an editor for the Psychiatric Pharmacy Review Course and is a past member of the College of Psychiatric and Neurologic Pharmacists (CPNP) Foundation Board and a past Secretary of the CPNP Board of Directors. She is a consultant to the Psychotropic Consultation Program for the Department of Child Services/Indiana University School of Medicine, Department of Psychiatry and serves as an expert panelist for several Project ECHO series on opioid use disorder for the Indiana University School of Medicine and the LGBTQ+ ECHO for the Indiana University Fairbanks School of Public Health.

Where do I even start?

Establishing a new clinical pharmacist service in the outpatient setting starts with evaluating what services the clinic currently offers and who is performing these services. In the outpatient clinic, medication management is generally provided by the physician and the nurse. The physician evaluates the effectiveness of medication, makes medication or dosing changes as appropriate, and monitors side effects. The nurse is often also involved in obtaining vital signs, weight, and providing medication refills. Within this system, the clinical pharmacist should look at what a pharmacist could provide that would supplement these services, reduce medication evaluation burden from the physician, and increase monitoring of side effects and medication adherence. The pharmacist is not a federally recognized provider for Medicaid or Medicare; these services are provided by the pharmacist under collaborative practice agreements and referrals and are billed under what is known as a “facility fee” for use of office space and other overhead costs. Specific services, such as medication regimen evaluation, provision of refills, and laboratory orders and monitoring, are not billed as individual services by the pharmacist, but are billed by the health system under the facility fee. Reimbursement for pharmacist services is paid directly to the health system. Individual states may recognize the pharmacist as a billing provider; the clinical pharmacist desiring to set up a billing practice should check with the state to see if the pharmacist is a recognized provider and what specific services are billable. The state Medicaid providers will be aware of this information.

What strategies do you recommend to get buy-in for pharmacist billing from the facility or other staff members?

If the clinic does not currently have a clinical pharmacist providing services, the pharmacist will need to contact the clinic administration and physician/treatment teams to spend time in the clinic to build support for clinical pharmacist services. Administrative and clinical pharmacy management support is imperative in developing a new outpatient clinical pharmacy practice. Establishing metrics to measure to support the clinical pharmacist are helpful in engaging administration. Metrics can include laboratory ordering/monitoring, medication reconciliation/refills, prescription drug monitoring program evaluation, prior authorization completions and avoidance, and how often the patient shows up for clinic appointments. The success of metrics should be documented and shared with clinic administration and staff, including any cost savings that are relevant for the metrics. For example, if physicians and nurses are spending time on prior authorizations and the pharmacist takes on this responsibility, the cost in time saved by those staff should be a part of the cost document. If the pharmacist begins to see patients who are stable and simply need medication monitoring and refills, do the physicians and nurses have more time to see other patients? This may also be a cost-saving measure. Many physicians are now required to run prescription drug monitoring program reports and evaluate them for their patients. The pharmacist may do this for them, saving their time and providing a service for the pharmacist that may be billed under the facility fee.

What contacts and resources are essential in making billing for services a success?

The physicians or psychiatrists that lead the treatment teams and clinic administration or clinical pharmacy managers are the initial contacts for starting a new service. The expectations of the physicians should be addressed and validated. The clinical pharmacist should expect to spend time “proving themselves” to the treatment team and establishing trust with the team for the pharmacist. Clinic, physician, and clinical pharmacy administration will need to be supportive of the expansion of services and be willing to advocate for the pharmacist with the clinic team. If there are other outpatient clinical pharmacist services already existing in the health system, the clinic model used by these pharmacists may serve as a foundation for developing a new service and understanding how to transition the model.

What is the biggest challenge in establishing a billing system in a new setting?

It is important to be familiar with the possible types of billing available to pharmacists. Reviewing the CMS Manual Regulations can be helpful in understanding “incident to physician” billing for the coverage of outpatient therapeutic services and services and supplies. Pharmacists are not recognized providers, but can bill as “incident to physician” as non-physician healthcare providers. In large health systems, there is usually a developed system of billing that can be implemented for new outpatient clinical pharmacy services; outpatient clinics that are independent may not be familiar with “incident to” billing which would require the clinical pharmacist to be familiar with CMS regulations and their application. There has been CMS guidance that pharmacists can bill the CPT codes 99211-99215 as “incident to”. MTM CPT codes used in the community pharmacy setting cannot be used in outpatient clinics for clinical pharmacist services. It is also important to be familiar with billing options in individual states. A few states allow pharmacist billing as a recognized provider in state Medicaid programs or commercial insurance payers. In the past two years, because of the expanded need for health care providers due to the COVID-19 pandemic, there is increasing interest in the role of pharmacists in providing telehealth services. Pharmacist-provided telehealth services can be billed “incident to” and requires the use of both audio and video technology. The Department of Health and Human Services tips for providers for billing for telehealth services, available online.

What are some tips to showcase a successful pharmacy service via billing?

Developing good pharmacy metrics to evaluate and report are an important part of justifying a clinical pharmacist outpatient service. The rate at which patients show up for appointments (show rate) can be an important metric to highlight billing, especially if the clinical pharmacist can bill as “incident to physician”. In addition to the actual billing of the appointment, a high show rate can also be used to highlight interventions related to medication adherence and improved rates of laboratory and other monitoring. Mental health medications lead to metabolic side effects and the rates of monitoring can be improved in most clinic settings. In addition to ordering and evaluating this monitoring, the clinical pharmacist may be able to make referrals to a primary care setting or initiate medications to treat these disorders. Highlighting this monitoring and primary care referrals can improve physician “buy-in” and increase adherence to quality indicators and metrics. The pharmacist impact on CMS quality measures may also be used as metrics to support the role of the clinical pharmacist. These measures may be found at online. Pharmacists may improve timely care, health promotion and education, medication reconciliation, vaccination rate, tobacco use assessment and intervention, and fall risk, as well as medication use in at-risk populations. The Pharmacy Quality Alliance (PQA) also has measures for the health insurance marketplace and CMS that may be impacted by pharmacist services. These can be found online. The types of billing reimbursement may not cover the pharmacist salary, but increased support for clinical pharmacist services in the outpatient setting may be gained by improvement in quality measures.

25 Years!