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Compliance Billing/Coding

  1. Question Compliance Billing/Coding
    Medical Coding Books
    Has anyone run across this or know how I can find the answer? I've looked on line, but so far no finding what I need. Does anyone know how to bill for a pharmacist in the physicians office conducting diabetic and PT/INR clinics? Currently it is being billed incident to and level 99213. Is this compliant with guidelines?

  2. #2
    What about the 99605/99606?

    It doesn't sound right to me to bill a pharmacist incident to a doctor. I have never run across this situation so I have never researched it.

    I found this from CIGNA medicare.


    Pharmacists' services and Office Visits
    Q: Can a pharmacist bill "incident to" when providing medication counseling in a physician's office?

    A: No, because there is no benefit category under Medicare for pharmacists so the only level they might qualify for billing under the physician's number (provided all "incident to" requirements were met) would be CPT code 99211 (the lowest level established patient office visit); and pharmacists may not "split/share" visits with physicians/non-physician practitioners.

    This is another link I found,

    Billing Using Incident to Physician Services. Billing using incident to physician services is an option for pharmacists practicing in physician offices. This strategy is particularly useful since pharmacists cannot bill Medicare directly for patient care services. Medicare currently does not recognize pharmacists as providers. Incident to physician services allows physicians to bill for services provided by nonphysicians. This avenue for billing applies only within the physician office; therefore, the pharmacy clinic would have to be located within a physician clinic to consider using this strategy. The criteria for use, which must be strictly adhered to, are as follows: the service must be " integral, although incidental, part of the physician's professional service"; "...commonly furnished in physicians' office"; and provided under direct supervision of a physician.[47]

    According to the definition of direct supervision in the Medicare Carrier's Manual, "...the physician must be present in the office suite and immediately available to provide assistance and direction."[47] The word "suite" has been widely interpreted; thus, if any ambiguity exists, the local Medicare representative should be consulted. One important addition is that in clinics with several physicians, the supervising physician does not have to be the physician who referred the patient.[47] The manual does not discuss how this should be documented in the patient chart. If the pharmacist's services meets the incident to physician criteria, and the patient has previously been seen by a physician in the clinic, then the physician can bill for a low-level office visit (billing code 99211 on Centers for Medicare and Medicaid Service [CMS] form 1500).[48] This strategy may also be available for third-party payers.

    In addition, several Medicaid and third-party insurers recognize pharmacists as providers, either directly or through a Medicaid demonstration project. In these cases, the pharmacist may be allowed to bill at a level higher than the low-level office visit. Consulting with the specific insurance carriers and the state Medicaid office can help in determining how and at what level visits can be billed.

    Hope this helps,

    Laura, CPC

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