Pharmacist Compensation for Cognitive Services: Focus on the Physician Office and Community Pharmacy

Abstract

We provide a stepwise approach for the clinical pharmacy practitioner in the physician clinic or community pharmacy setting to secure compensation for cognitive services. How to establish compensation for pharmacist services is explored, including evaluating the payer mix, developing a relationship with the first- or third-party payer, becoming credentialed with a third-party payer, and creating a fee structure. We detail the physical process of billing, which involves completing appropriate billing forms, appropriately using billing codes, documenting cognitive services in the patient record, and obtaining the proper waivers and/or approvals to provide specific services such as laboratory services and immunizations. This comprehensive review of compensation for cognitive services available in the community pharmacy and physician office environment is designed to be a template for pharmacists to further develop specific strategies, implement fee structures, and obtain compensation in their pharmacy environment and payer mix. Exploration into these innovative markets will enable pharmacists to increase revenue as they enhance and expand their cognitive services for patients.

Clinical Pharmacy Services in Heart Failure: An Opinion Paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network

“…In 2005, Current Procedural Terminology codes were created for MTM to allow pharmacists to submit billing for these activities, generating revenue for the activity from both third‐party and Medicare Part D plans . Provisions of MTM were strengthened in the Affordable Care Act of 2010, which not only specified pharmacists as eligible providers of MTM, but also focused on a patient‐centered team approach to health care .…”

Billing for pharmacists' cognitive services in physicians' offices: Multiple methods of reimbursement

“…7 CPT codes for evaluation and management for outpatient visits commonly used in physician practices include 99211, 99212, 99213, 99214, and 99215 and may be referred to as level 1-5 visits. 6 Table 2 describes the characteristics of CPT codes used by physicians for established patients as well as the 2011 Medicare fee schedule for CPT codes in North Carolina. 17 Level 1 visits have the lowest fee ($19.06), whereas level 5 visits have the highest charge ($133.56).…”

“…[1][2][3][4][5] Despite the benefits of MTM services for individual patients and the health care system, these services are not consistently reimbursed. 6 Historically, pharmacists have billed for product delivery but not for cognitive services. During the past decade, the profession has focused on obtaining provider status for pharmacists and developing sustainable reimbursement models for direct patient care services.…”

Cognitive pharmaceutical services and the community pharmacist: are South African patients receiving them and are they willing to pay?

“…11 While some progress has and is being made in a number of countries in addressing this problem, 4,12,13 patient willingness-to-pay and third-party payment for cognitive services remains a challenge for the profession. [14][15][16][17][18] Most pharmaceutical care studies report positive clinical outcomes. However, there exists very little robust data on economic (cost-effective) and humanistic (health-related quality of life) outcomes, 11,18 further compounding concerns relating to pharmacist compensation.…”