| Payment for Professional Pharmacist Services Issues National Provider Identifier (NPI) ASCP Policy Statements/Issue Papers Relating to Professional Pharmacy Services Coalitions and Work Groups Glossary of Professional Services/Billing Terms Resources Issues Medication Therapy Management Services (MTMS) Provision in Medicare Part D The Medicare Modernization Act, which established the Medicare Part D prescription drug benefit, requires prescription drug plans (PDPs) to cover Medication Therapy Management Services (MTMS) that may be provided by pharmacists. While CMS has not clearly defined MTMS and is leaving many details to the individual prescription drug plans participating in the Part D program, a definition has been approved by 11 national pharmacy associations. ASCP sees the provision for MTMS as an opportunity for pharmacists to be paid for services that promote the appropriate use of medications in high-risk patients. For more information, including answers to common MTMS questions, visit ASCP’s Medicare Drug Benefit: Questions and Answers issue paper. October 2008 ASCP Comments to CMS on HIPAA Electronic Transaction Standards for Billing Pharmacists' Professional Services The Centers for Medicare & Medicaid Services (CMS) released a Notice of Proposed Rule Making (NPRM) on August 22, 2008 that proposed pharmacists' professional services be billed either via the NCPDP Telecommunication standard (the way medications are billed by pharmacies now) OR the X-12 standard (the way physicians and other health care professionals bill for their services). Previously, CMS said professional services could only be billed using X-12, so their August 22 proposal was a departure from their previous decision. Using the NCPDP standard helps pharmacies who want to integrate billing medication therapy management services into their current work flow,but the X-12 standard must remain an option for those pharmacists who do not work in a pharmacy. ASCP cautiously agreed with CMS' proposal to use either standard, but ASCP urged CMS to adopt policies ensuring complete separation of product billing from service billing. To view ASCP's comments, click here. To view CMS' Proposed Rule on Electronic Transaction Standards, click here. Legislative Efforts to Recognize Pharmacists as Healthcare Providers: Medicare Clinical Pharmacist Practitioner Services Coverage Act of 2004 In June of the 2004 session of Congress, North Carolina Representative Richard Burr introduced a bill, HR 4724, entitled the Medicare Clinical Pharmacist Practitioner Services Coverage Act of 2004 allowing for the recognition of pharmacists as providers of healthcare services in Part B of the Medicare program. This new legislation proposes an amendment to the section of the Social Security Act that provides coverage of services under Medicare Part B. The amendment adds a “Clinical Pharmacist Practitioner” (CPP) to the list of physician-extenders already being reimbursed for their services under Medicare. In order to receive reimbursement, a CPP would have to enter into a collaborative practice agreement with a physician. On July 7, 2004, the bill was referred to the House Subcommittee on Health. At this time, Congress has taken no further action on this bill. It is important to note that in fall 2004, Burr was elected to the Senate, and the Bill he introduced in the house has stalled in committee. National Provider Identifier (NPI) The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard unique identifier for health care providers. The National Plan and Provider Enumeration System (NPPES) collects identifying information on health care providers and assigns each a unique National Provider Identifier (NPI). As of May 23, 2005, all health care providers can apply for their National Provider Identifier (NPI). The NPI will replace health care provider identifiers in use today in standard health care transactions. The health plans with which you do business will instruct you as to when you may begin using the NPI in standard transactions. All HIPAA covered entities except small health plans must begin using the NPI on May 23, 2007. The Centers for Medicare and Medicaid Services (CMS) has announced that Medicare fee-for-service claims submitted using the NPI will be accepted beginning January 3, 2006 if they are also submitted with a legacy Medicare number. Beginning October 1, 2006, claims may be submitted using the NPI alone, but the legacy Medicare numbers will also be accepted. As of May 23, 2007, legacy numbers will no longer be accepted, and the NPI will be the only identifier providers can use to be reimbursed for their services. Click here to view an overview of the NPI Final Rule. Apply online now for your NPI. ASCP Policy Statements/Issue Papers Relating to Professional Pharmacy Services Coalitions and Work Groups Pharmacist Provider Coalition (PPC) ASCP is a member of the Pharmacist Provider Coalition (PPC), which unites seven national pharmacist organizations to advocate for improvements in the quality of care that Medicare patients receive from their medications. Health care teams across the U.S. are missing out on pharmacist medication therapy management services because Medicare does not recognize pharmacists as "health care providers." The majority of third-party payers follow Medicare’s lead in setting reimbursement policies, and therefore do not cover pharmacists’ services. PPC was successful in helping to make sure the Medicare Modernization Act of 2003 provides reimbursement for Medication Therapy Management Services (MTMS) that pharmacists perform. However, PPC is continuing their work to achieve health care provider status for pharmacists to ensure broad patient access to these services and preserve the role of pharmacists on the health care team. More information about the Pharmacist Provider Coalition and the participating associations can be viewed at their official website. Pharmacist Services Technical Advisory Coalition (PSTAC) PSTAC was founded in 2002 to improve the coding infrastructure necessary to support billing for pharmacists' professional services. The PSTAC coalition membership is comprised of 8 national pharmacist organizations, including ASCP. The Coalition works to provide the national leadership necessary to position and secure pharmacy's place in the electronic data interchange (EDI) health encounter/claims processing and payment environment concerning all health care providers' professional services. ASCP encourages you to visit the PSTAC website. Don’t be afraid to spread the word to your fellow pharmacists about PSTAC and their groundbreaking work in pharmacy practice. National Council for Prescription Drug Programs (NCPDP) Work Group 10 – Professional Pharmacy Services Work Group 10 - Professional Pharmacy Services assists in the development and maintenance of standards to support electronic documentation and transmission of data for professional pharmacy services. This Work Group’s goals include monitoring initiatives and industry concerns related to on-line Drug Use Review (DUR) and Professional Pharmacy Services (PPS), specifically those regarding billing transactions for such activities. If you are interested in getting involved with this workgroup, please contact ASCP's Policy & Advocacy Department at ProfAff@ascp.com Glossary of Professional Services/Billing Terms ASC X12N and X12N 837 – X12 is the committee responsible for the development and maintenance of American National Standards for Electronic Data Interchange (EDI). X12N is the insurance subcommittee of X12. X12N 837 refers to health care insurance claims for professional services, including professional physician/pharmacist services, disease management, and durable medical equipment. PSTAC has developed a Pharmacy Companion Guide, which provides instruction on the data transaction segments of the ASC X12N 837 Insurance Subcommittee Implementation Guide (IG) Health Care Claim: Professional that are germane to pharmacy along with sample cases from disease management claims and durable medical equipment (DME) claims. Click here for more information on the Pharmacy Companion Guide. CPT Codes – Current Procedural Terminology (CPT) Codes are numeric codes developed by the American Medical Association to classify the services provided by medical and other health practitioners. This has been established as the standard code set for reporting health care services in electronic transactions according to HIPAA. For a more detailed description of CPT codes, please click here. HCFA 1500 / CMS 1500 – HCFA 1500 is a form developed by the Health Care Financing Administration (HCFA, now CMS) to bill outpatient, Medicare Part B claims. This form is used not only by Medicare, but also other private insurance providers. It has traditionally been available in a printed format, but is now available in an electronic format for electronic billing of claims. The electronic claim version of the CMS 1500 form is the X12N 837, which uses CPT and HCPCS codes. Resources Developing a Senior Care Pharmacy Practice: Your Guide and Tools for Success |
