Can a Pharmacist Bill 98966?

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Can a Pharmacist Bill 98966? Unveiling the Truth

The answer to the question, Can a Pharmacist Bill 98966? is yes, under specific circumstances. Pharmacists can bill CPT code 98966 for non-face-to-face prolonged service(s) of 30-60 minutes for care management services provided remotely, meeting certain criteria.

Understanding CPT Code 98966

CPT code 98966 represents a non-face-to-face prolonged service code used by various healthcare professionals, including pharmacists, to bill for extended time spent providing care management services. It’s crucial to understand the specific requirements for utilizing this code to ensure proper billing and avoid potential audits.

Eligibility Requirements for Pharmacists

Not all pharmacists can bill CPT code 98966. Eligibility is determined by factors such as:

Scope of Practice: The pharmacist’s scope of practice within their state or jurisdiction must allow them to provide care management services.
Credentialing: Many insurance companies require pharmacists to be credentialed as providers before they can bill for services. This typically involves providing documentation of education, licensure, and liability insurance.
Supervising Physician/Provider: The pharmacist may be required to work under the supervision or in collaboration with a physician or other qualified healthcare provider, depending on the payer and applicable regulations.
Payer Requirements: Each insurance payer (Medicare, Medicaid, commercial insurers) has its own specific guidelines for billing CPT code 98966. Pharmacists must verify these guidelines before submitting claims.

Services Covered Under CPT Code 98966

CPT code 98966 covers a range of non-face-to-face care management services provided by pharmacists. These services may include:

Medication Reconciliation: Reviewing a patient’s medication list to identify and resolve discrepancies.
Adherence Counseling: Providing education and support to help patients adhere to their medication regimens.
Disease State Management: Monitoring patients with chronic conditions and providing interventions to improve outcomes.
Care Coordination: Communicating with other healthcare providers to ensure coordinated care.
Patient Education: Providing education about medications, disease states, and self-management techniques.
Drug Therapy Monitoring: Reviewing patient lab values, medication lists, and potential interactions to identify and manage therapy changes.

The Billing Process for CPT Code 98966

The billing process for CPT code 98966 involves several steps:

Patient Assessment: Conduct a thorough assessment of the patient’s needs to determine the appropriate care management services.
Service Delivery: Provide the non-face-to-face care management services, ensuring accurate documentation of the time spent.
Documentation: Document the services provided, including the date, time, duration, and specific interventions.
Coding and Billing: Assign the correct CPT code (98966) and submit the claim to the payer.
Follow-up: Track the claim status and address any denials or rejections promptly.

Common Mistakes to Avoid

Several common mistakes can lead to claim denials when billing CPT code 98966:

Insufficient Documentation: Failing to adequately document the services provided, including the time spent and specific interventions.
Incorrect Coding: Using the wrong CPT code or modifier.
Lack of Eligibility: Not meeting the eligibility requirements for billing CPT code 98966.
Exceeding Time Limits: Billing for less than 30 minutes or more than 60 minutes.
Billing for Face-to-Face Services: CPT code 98966 is specifically for non-face-to-face services. Face-to-face encounters require different billing codes.

Benefits of Billing CPT Code 98966

Billing CPT code 98966 can provide several benefits to pharmacists and their patients:

Revenue Generation: Provides a mechanism for pharmacists to be reimbursed for their time and expertise in providing care management services.
Improved Patient Outcomes: Allows pharmacists to provide comprehensive care that can improve patient health outcomes and reduce healthcare costs.
Enhanced Patient Access: Expands access to care management services for patients who may not be able to attend in-person appointments.
Increased Pharmacist Value: Demonstrates the value of pharmacists as integral members of the healthcare team.

Can any pharmacist immediately start billing 98966?

No, not immediately. As mentioned above, several factors determine eligibility. Credentialing, scope of practice, payer policies, and supervising agreements all must be in place before billing 98966. Many insurance companies require pharmacists to be enrolled in their network to be reimbursed for services.

What kind of documentation is required when billing CPT 98966?

Thorough documentation is essential. The medical record should clearly reflect the date, duration, and specific content of the interaction. Examples include medication reconciliation results, adherence counseling interventions, disease state management progress, and communication with other healthcare providers. A precise start and end time for the call should also be documented.

What if the prolonged service goes beyond 60 minutes?

CPT code 98967 is available for non-face-to-face prolonged services exceeding the initial 60 minutes covered by 98966. It should be used in conjunction with 98966 to represent each additional 30 minutes of service. Proper documentation of the entire service time is crucial.

Is CPT code 98966 only for phone calls, or can it include other forms of communication?

While commonly used for phone calls, CPT code 98966 covers any non-face-to-face communication, including secure email, telehealth platforms, or other forms of remote communication. The key is that there isn’t a physical encounter between the pharmacist and the patient.

How often can I bill CPT code 98966 for the same patient?

The frequency of billing CPT code 98966 varies depending on payer guidelines and the patient’s needs. Some payers may limit the number of times this code can be billed per month or year. Therefore, it’s imperative to verify payer-specific policies beforehand.

What happens if my claim for 98966 is denied?

If your claim is denied, carefully review the reason for denial provided by the payer. Common reasons include insufficient documentation, incorrect coding, or lack of eligibility. Correct any errors and resubmit the claim with supporting documentation. If necessary, appeal the denial.

Does Medicare reimburse pharmacists for CPT code 98966 directly?

Traditionally, Medicare has not directly reimbursed pharmacists for CPT code 98966 in all settings. However, there are opportunities for reimbursement through collaborative practice agreements or incident-to billing under the supervision of a physician or other qualified healthcare provider. Always verify the most current Medicare policy.

How can I find out about the specific billing requirements for different insurance companies?

Contact the payer directly or visit their website to obtain their specific billing guidelines. Many insurance companies have provider manuals or online resources that outline their coding and billing policies, including those for CPT code 98966.

What role does collaborative practice agreements play in pharmacists billing 98966?

Collaborative practice agreements allow pharmacists to provide care management services under the supervision of a physician or other qualified healthcare provider. This can expand the scope of practice for pharmacists and enable them to bill CPT code 98966 for services that would otherwise be outside their legal authority.

Is prior authorization required to bill CPT code 98966?

Prior authorization requirements vary by payer. Some insurance companies may require prior authorization before allowing a pharmacist to bill CPT code 98966, while others may not. Always check with the payer to determine if prior authorization is required.

How does CPT code 98966 differ from other remote patient monitoring codes?

CPT code 98966 is specific to prolonged, non-face-to-face services, where the service exceeds typical medication management counseling. Other remote patient monitoring (RPM) codes often involve the use of technology to collect and transmit patient data. 98966 can be used in conjunction with RPM or as a stand alone code.

Can a pharmacist bill CPT 98966 if the service provided involves medication therapy management (MTM)?

Yes, it can. CPT code 98966 could potentially be billed for non-face-to-face MTM services if the services provided are comprehensive, require prolonged time (30-60 minutes), and meet the criteria. It’s crucial to document the specific MTM activities performed and the time spent to support the claim.