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KEY POINTS

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  • Medical service billing is an essential process between a healthcare provider and a payer.

  • In the United States, the medical service billing system is based on the American Medical Association's (AMA) Current Procedural Terminology (CPT) coding system.

  • Pharmacist providers billing for patient care services must obtain and use a National Provider Identifier (NPI) number for both service documentation and claim forms.

  • Medication therapy management services (MTMS) codes (99605, 99606, and 99607) were devel-oped specifically to describe pharmacists' patient care services.

  • "Incident to" billing is when a physician serves as the primary billing party to facilitate payment for patient care services provided by other healthcare professionals or staff members.

  • The Transitional Care Management Services (TCMS) codes were added to the AMA CPT code-book in 2013 and reflect the importance of reducing hospital readmissions.

  • The Complex Chronic Care Coordination (CCCC) codes describe patient-centered management and clinical support services provided by a physician or other qualified healthcare provider and their staff on an outpatient basis on a per month basis.

  • It is imperative to identify and confirm whether the payer will pay for the services before the services or procedures are provided.

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INTRODUCTION

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Medical service billing is an essential process between a healthcare provider and a payer. There are many different models for payer-provider relationships, including fee-for-service, capitated rate sche-dules, bundled payments, and integrated health plans (employer model). As pharmacists have evolved their scope of patient care services, traditional medical billing processes (ie, American Medical Association's [AMAs] Current Procedural Terminology codes) were developed similar to physician services to ensure viable revenue to support the delivery of these clinical services.1 Medical service billing, including for pharmacists' services, is not limited to commercial insurance or government healthcare agencies. Healthcare providers commonly invoice patients directly for elective and specialty services or procedures. Payment for medical services may be obtained from many different entities, including:

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  • Private payment (patient, family, caregivers)

  • Health insurance

  • Health plans

  • Patient-centered medical homes

  • Accountable care organizations

  • Medicare Part D (state prescription drug programs)

  • Government health agencies (Medicare, Medicaid, Tricare, VA)

  • Employer-based programs

  • Retirement programs

  • Self-insured companies

  • Indigent health plans

  • 340B prescription programs

  • Charitable programs

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It is important for pharmacists to understand the foundation of the medical billing process to ensure compliance prior to delivering patient care services. Pharmacists have made significant progress integrating into the national medical billing environment and are now recognized as healthcare providers who play an essential role in the healthcare system by optimizing medication therapy, improving health outcomes, and reducing risks associated with pharmacologic treatment.

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Medical Services Billing Framework

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In the United States, the medical service billing system is based on the American Medical Association's (AMA) Current Procedural Terminology (CPT) coding system. CPT represents a master set of medical billing codes, descriptions, and guidelines for healthcare services and procedures. Historically the CPT codebook was physician-centric, but now it includes ...

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