Can a Pharmacist Bill a 99212?
Yes, under specific circumstances and with proper credentials, a pharmacist can bill for a 99212 outpatient evaluation and management (E/M) code. This article will delve into those circumstances, providing a comprehensive understanding of when and how pharmacists can appropriately utilize this billing code.
The Evolving Role of Pharmacists in Patient Care
Pharmacists are increasingly playing a pivotal role in direct patient care, extending beyond dispensing medications. This expanded role includes services like medication therapy management (MTM), chronic disease management, and immunizations. As pharmacists take on these responsibilities, the question of appropriate billing for their services becomes increasingly important. The 99212 code represents a level 2 established patient visit and signifies a specific level of clinical service.
What is a 99212 E/M Code?
The 99212 code is a Current Procedural Terminology (CPT) code used for billing an office or other outpatient visit for the evaluation and management of an established patient. Specifically, it describes a visit that typically involves:
- A problem-focused interval history: Focusing on changes since the last visit.
- A problem-focused examination: Limited to the affected body area or organ system.
- Straightforward medical decision making: Low complexity.
This code is often used for brief follow-up visits for stable chronic conditions or for acute, self-limited problems. It’s crucial to understand these criteria to determine if a pharmacist’s services justify its use.
When Can a Pharmacist Bill a 99212?
The ability for a pharmacist to bill a 99212 code depends on several factors, including state regulations, payer policies, and the specific services provided. Key considerations include:
- State Scope of Practice: Some states grant pharmacists broader prescriptive authority and patient care responsibilities than others. This directly impacts their ability to perform the elements required for a 99212 code.
- Collaborative Practice Agreements: Pharmacists often operate under collaborative practice agreements (CPAs) with physicians. These agreements define the scope of services a pharmacist can provide and may authorize them to bill for E/M codes.
- Payer Policies: Insurance companies and government payers (like Medicare) have specific rules about which providers can bill for which services. It’s essential to verify coverage before submitting a claim.
- Incident-To Billing: In some cases, a pharmacist’s services may be billed “incident to” a physician’s services. This means the pharmacist’s service is provided as part of a physician’s overall care plan, and the physician bills for it.
Essential Requirements for Billing a 99212
If a pharmacist can bill a 99212 based on the factors mentioned above, several requirements must be met:
- Proper Documentation: Detailed documentation is crucial. The medical record must clearly demonstrate the history taken, the examination performed, and the medical decision-making process.
- Medical Necessity: The service must be medically necessary. This means it must be reasonable and necessary for the diagnosis or treatment of an illness or injury.
- Qualified Provider Status: The pharmacist must meet the payer’s definition of a qualified healthcare provider. This may involve specific certifications or training.
- Accurate Coding: Choosing the correct CPT code is essential. The 99212 code should only be used when the service aligns precisely with the CPT description.
Common Mistakes to Avoid
Billing errors can lead to claim denials and potential audits. Here are some common mistakes to avoid when attempting to bill a 99212:
- Billing for Services Outside Scope of Practice: Ensure the services provided fall within the pharmacist’s authorized scope of practice under state law and collaborative agreements.
- Insufficient Documentation: Inadequate documentation is a frequent reason for claim denials. Provide detailed notes that support the level of service billed.
- Lack of Medical Necessity: Only bill for services that are medically necessary. Convenience or routine services may not be covered.
- Incorrect Coding: Using the wrong CPT code is a common mistake. Ensure the 99212 code accurately reflects the services provided.
- Failure to Verify Payer Coverage: Always verify coverage with the payer before submitting a claim to ensure the service is eligible for reimbursement.
Benefits of Pharmacist Billing for 99212
Allowing pharmacists to bill for services like a 99212 can offer several benefits:
- Improved Patient Access: Pharmacists are often more accessible than physicians, particularly in underserved areas.
- Reduced Healthcare Costs: Pharmacist-led interventions can help prevent hospitalizations and reduce overall healthcare spending.
- Enhanced Medication Adherence: Pharmacists can play a key role in improving medication adherence and optimizing drug therapy.
- Greater Efficiency: Allowing pharmacists to manage stable chronic conditions can free up physicians to focus on more complex cases.
Examples of Scenarios Where a Pharmacist Might Bill a 99212
Here are some examples where a pharmacist might appropriately bill a 99212:
- Diabetes Management: A pharmacist working under a collaborative practice agreement follows up with a patient whose blood sugar levels are stable but requires ongoing monitoring and medication adjustments.
- Hypertension Management: A pharmacist monitors a patient’s blood pressure, adjusts medication dosages according to a pre-approved protocol, and educates the patient on lifestyle modifications.
- Anticoagulation Management: A pharmacist monitors a patient’s INR levels, adjusts warfarin dosages, and provides education on signs and symptoms of bleeding.
Frequently Asked Questions
Can a Pharmacist Bill a 99212 If They Don’t Have a Collaborative Practice Agreement?
- This is highly unlikely and depends significantly on state laws. Without a collaborative practice agreement or similar authorization, the pharmacist’s scope of practice may not allow them to perform the necessary components of a 99212 service (history, examination, medical decision-making) and bill for it.
What Kind of Documentation is Required to Support a 99212 Claim?
- The documentation must include a problem-focused interval history, a problem-focused examination, and a clear demonstration of straightforward medical decision-making. It should also document the medical necessity of the service and the patient’s response to treatment.
Is Incident-To Billing a Viable Option for Pharmacists Billing 99212?
- Yes, “incident to” billing can be a viable option, but it requires close supervision by a physician. The pharmacist’s services must be an integral part of the physician’s treatment plan, and the physician must be physically present in the office.
What Happens if a Pharmacist’s 99212 Claim is Denied?
- If a claim is denied, the pharmacist should review the denial reason, correct any errors in the documentation or coding, and resubmit the claim. If the denial is due to payer policy, the pharmacist may need to appeal the decision.
Are There Specific Certifications Pharmacists Need to Bill 99212?
- While there aren’t always specific certifications universally required, payers may prefer or require pharmacists to have specific certifications relevant to the services they are providing, such as certification in diabetes management or anticoagulation therapy.
How Do State Laws Impact a Pharmacist’s Ability to Bill 99212?
- State laws significantly impact a pharmacist’s ability to bill for E/M codes. States with broader scope of practice laws are more likely to allow pharmacists to perform the services necessary to bill a 99212.
Does Medicare Reimburse Pharmacists for 99212 Services?
- Medicare’s reimbursement policies for pharmacist-provided services are complex and evolving. Currently, direct reimbursement for services like a 99212 is limited, but pharmacists can often bill “incident to” a physician’s service under specific conditions.
What are the Key Differences Between a 99212 and a 99213 Code?
- The key differences lie in the level of history, examination, and medical decision-making. A 99213 requires a more detailed history and examination than a 99212, and the medical decision-making can be of low to moderate complexity.
Can a Pharmacist Bill 99212 for Medication Therapy Management (MTM) Services?
- In some cases, yes, but it depends on the specific MTM services provided and whether they meet the criteria for a 99212 visit. Many MTM services are billed under different codes, but if the service involves a problem-focused visit for an established patient with straightforward medical decision making, a 99212 might be appropriate.
Are There Any Legal Risks Associated with Pharmacists Billing 99212?
- Yes, there are legal risks, including potential violations of fraud and abuse laws if the services are not medically necessary, properly documented, or accurately coded. It is crucial for pharmacists to comply with all applicable laws and regulations.
How Can Pharmacists Stay Up-to-Date on Billing Regulations and Payer Policies?
- Pharmacists can stay up-to-date by joining professional organizations, attending continuing education programs, subscribing to industry publications, and regularly reviewing payer websites for policy updates.
Besides 99212, Are There Other CPT Codes Pharmacists Can Bill?
- Yes, depending on their scope of practice and the services they provide, pharmacists may be able to bill for other CPT codes, such as those for immunizations, medication reconciliation, and chronic care management. The specific codes will vary based on the services rendered and payer policies.