Pharmacists Recognized As A Provider: Are You Prepared?
By Roger S. Klotz, R.Ph., BCNSP, FASCP, FACA, FCPhA, CDM
Care Partners Consulting Pharmacist, LLC.
The passage of the Medicare Modernization Act of 2003 which created Medicare Part D also created the concept of reimbursement for Medication Therapy Management (MTM) by Medicare. The pharmacist was named directly as a healthcare provider of this service while other healthcare professionals were indirectly mentioned. This statement in the law recognizes the pharmacist as a healthcare provider of patient care services. This is exciting news for the practicing pharmacist who wants to add patient focused care such as MTM services to the services provided in their practice. This is a major step and presents all pharmacists with a significant opportunity, not only from a professional practice standpoint but also from business growth potential. To participate as a provider and take advantage of this new opportunity the pharmacist will have to gain an understanding of the processes needed to provide Cognitive Services and also receive reimbursement. This will require the pharmacist to create and implement new policies and procedures related to professional practice, clinical documentation, and reimbursement processes. Thus, 2007 will be an interesting, challenging, and exciting year for pharmacists, their practice, and their organizations.
In 2007 there are a number of major changes that will affect pharmacists and their organizations. The following will be required for those who want to bill for all services, especially MTM and other Cognitive Services:
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ICD-10 Coding System is Scheduled to Replace ICD-9 Coding System On October 1, 2007:
The World Health Organization‘s (WHO) International Classification of Diagnosis version 10 (ICD-10) coding system will replace the now outdated ICD-9 system. There is a concern about the implementation because the ICD-10 system is a move to a seven-digit format compared to the 5 digit format used in the ICD-9 version. This change will require major program alterations across the healthcare system, especially in the provider’s software. The ICD-10 is a more clinically focused diagnosis classification. In one case a major Health System is training all clinicians (i.e. nurses, physicians, pharmacists) in basic reimbursement since they will be the major classifiers and chose the proper code. This of coarse can be a major issue for all healthcare professionals because the traditional reimbursement approaches will have to be significantly modified. Therefore, it creates an issue of significant increased cost to all healthcare professionals and their organizations. The pharmacist, therefore, who provides the MTM/Cognitive Services must become familiar with reimbursement procedures and be fully trained in the use of the ICD-10 coding system. In order to submit your claim electronically you will have to provide the appropriate diagnosis code. For details regarding the ICD-10 coding system you can go to http://www.cms.hhs.gov/paymentsystems/icd9/icd10.asp.
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Health Care Provider Taxonomy Code Set now has new pharmacist codes and are required when billing for MTM/Cognitive Services:
The national claims group has updated the pharmacist/pharmacy Taxonomy Codes. Thus, pharmacists involved in the provision of MTM/Cognitive services will be required to indicate their areas of expertise when submitting a claim by using the appropriate taxonomy code (i.e. 1835N1003X – Pharmacist – Nutrition Support, 1835P1200X – Pharmacist- Pharmacotherapy) to submit an electronic health care claim. It is interesting to note that they have also added a Compounding Pharmacy code.
Payers using the Health Care Provider Taxonomy Code Set under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must by October 1, 2007 begin recognizing the pharmacist specialties code submitted by the provider(s).
The addition of the new code sets now contain 10-character alphanumeric codes and definitions specific for pharmacist; geriatrics, nuclear, nutrition support, oncology, pharmacotherapy, and psychiatric pharmacy service providers; pharmacy technician; and clinic, community/retail, compounding, Of the six pharmacist specialties in the code set, geriatrics is the only one whose definition states that the pharmacist requires a certification.
Pharmacists/pharmacies that have already completed the process of applying for a National Provider Identifier (NPI) should consider whether they need to update the Health Care Provider Taxonomy code in their NPI record.
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National Provider Identification number must replace all other identifiers (i.e. UPIN, NABP, DMERC Provider) by May 23rd of 2007:
The National Provider Identifier is the HIPAA-mandated identification number that contains no details about the health care provider. This identifier is a 10-digit unique individual number that corresponds to a single person or business entity. The details about the person or business are contained in the National Provider Identifier record and can only be accessed by the individual using the identification ID and personnel password. This approach does allow the individual or organization to modify their information when necessary. The government has set May 23, 2007 as the deadline by which all HIPAA-covered entities are required to use the National Provider Identifier to identify the health care provider in a standard electronic health care transaction. Small health plans have until May 23, 2008 to identify health care providers solely by their National Provider Identifier. Thus, the majority of payers must require the NPI number by May 23rd of 2007. Pharmacists, in particularly, those interested in providing MTM/Cognitive services must apply for their personnel NPI number as soon as possible. Their organization must also apply for their NPI number to continue to bill. In order for the pharmacist to register they should go to the NPPES Web site www.nppes.cms.hhs.gov/NPPES/welcome.do to obtain their individual NPI number.
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Pharmacist HIPAA compliant billing codes to be used when billing payers for MTM/Cognitive services are now available:
The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel has created the following pharmacist specific CPT codes:
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Code 0115T is the billing code for the first face-to-face encounter with a patient in a time increment of up to 15 minutes.
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Code 0116T is to be used with the same patient in a time increment of up to 15 minutes for a subsequent or follow-up encounter.
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Code +0117T is an add-on code that may be used to bill for additional increments of 15 minutes of time to either preceding codes.
The T in the code indicates that these CPT codes are temporary and therefore it is important for pharmacists to begin using these codes immediately so that they fully become part of the reimbursement system. Once when these codes are utilized on a regular basis will they be changed to permanent codes by the AMA panel.
Personally, I have created a standard invoice with these codes so that all I have to do is check the appropriate box when billing for the particular patient and the cognitive services provided.
While change is inevitable, it also does present pharmacists with an outstanding opportunity to enhance their practice, as well as add new revenue sources to their business. On the other hand, it will require pharmacists and their organizations to modify their business practices not only from a reimbursement standpoint, but also from a clinical documentation standpoint. The pharmacist providing MTM/Cognitive services will be required to create written consults to the patient and the patient’s physician in order to provide the appropriate documentation for obtaining reimbursement. Also this approach provides an enhanced medical-legal risk management program. The year 2007 will be a challenge to pharmacists and their organizations, but they will also be presented with a major professional and business opportunity.
In the next issue I will discuss the documentation approach I have developed as a provider of MTM/Cognitive services in a pharmacist’s private practice approach.