Helpful Ideas

Getting Paid for Warfarin Monitoring and Counseling

Problem: Several patients at my client long-term care facilities are receiving warfarin therapy, and I routinely provide monitoring and counseling services. How can I make sure I am being fully reimbursed for these services?

Solution: With thorough documentation and adherence to proper coding and claims filing guidelines, pharmacists should have no trouble being reimbursed in a straightforward, timely manner.

Pharmacists play a crucial role in warfarin sodium therapy by providing regular monitoring and counseling aimed at reducing the incidence of bleeding, clotting, and other serious side effects. To help pharmacists and other providers be fully reimbursed for these essential services, DuPont Pharma has published Provider Reimbursement Guide: Monitoring and Counseling Patients on Coumadin (Warfarin Sodium) Therapy, which includes detailed information on all aspects of documentation, coding, and third-party billing.

Reimbursable services provided to patients on warfarin include patient assessment for therapeutic effects and the need for physician referral; patient education and reinforcement relating to drug-drug and drug-food interactions and side effects; prothrombin time testing and interpretation; dose adjustment; ongoing counseling; and office or clinic visits. These services typically are provided in hospital outpatient clinics or anticoagulation clinics, physician offices or group practices, nursing homes, or in the home care setting.

For pharmacists, the reimbursement picture for warfarin monitoring and counseling is best in the private-pay arena, particularly when dealing with health maintenance organizations or large insurance companies with established preventive care benefits. When billing private insurers, pharmacists should use the form used by Medicare and Medicaid, the HCFA-1500 claim form. Claims should be coded in accordance with two universally recognized coding systems: the International Classification of Disease, 9th Edition-Clinical Modification (ICD-9) system; and HCFA's Common Procedure Coding System, which includes the Current Procedural Terminology, Fourth Edition (CPT-4) coding system of about 7,000 medical services and procedures. Generally, pharmacists will successfully secure reimbursement for only the lowest evaluation and management (E/M) service code, CPT-4 99211. And remember, the guide cautions: "Failure to correlate ICD-9 diagnosis codes and CPT-4 procedure codes properly can result in claims denial."

Private insurers' reimbursement policies vary widely, and pharmacists should check the specific policy of each, but general guidelines call for submission of the following items with each bill:

• A cover letter including a statement of the purpose of the claim, the patient's name and identification, the date of service, the anticipated outcomes, and a list of enclosed supporting documents
• A statement of medical need signed by a physician and including a formal declaration of the need for pharmacist services, as well as the projected duration of services and expected benefits
• A pharmacotherapy work-up and report including medical, drug, and compliance histories and other patient information; drug therapy problems; therapeutic alternatives and goals; recommendations; and a drug monitoring plan
• An invoice including a statement of the patient's problem, a comprehensive listing of interventions taken by the pharmacist, and information on outcomes of those interventions (i.e., changes in drug therapy or patient status) that are directly attributable to the pharmacist's interventions

Currently, the Medicare and Medicaid reimbursement picture is considerably less favorable. Medicare reimbursement for pharmacist services typically is provided under the "incident to" rule, which states that services performed by appropriate nonphysician providers can be billed as if performed by the physician, provided that the rendered service is integral to a physician's diagnosis or treatment plan, provided under the direct supervision of the physician, and normally provided in a physician's office or physician-directed clinic.

Claims submitted by pharmacists under the "incident to" rule must include the physician's provider number. If no physician encounter occurs at the time E/M services are rendered, services must be billed under the low-level CPT code 99211, regardless of the intensity of the service.

Medicaid currently reimburses pharmacists for prothrombin time testing but not counseling and other cognitive services. This may change soon, however, if HCFA pilot studies under way demonstrate that such services reduce overall drug therapy costs. Moreover, the guide notes: "As Medicare and Medicaid beneficiary enrollment in MCOs continues to grow, pharmacist billing of services will continue to emerge. The trend of commercial and BC/BS insurers to manage pharmacy benefits and associated costs as a separate 'carve-out' program through pharmacy benefit managers (PBMs) has been established in the marketplace and provides yet another option for pharmacists."

The DuPont guide also includes HCFA and private insurer claim forms and instructions, guidelines on using the universal Pharmacist Care Claim Form developed by the National Association of Retail Druggists, and a list of state insurance commissioners who can provide detailed information on reimbursement policies in your state.

In addition, DuPont offers a variety of support materials and programs related to warfarin services. For more information, call 800-COUMADIN or speak with any DuPont Pharma sales representative.

David K. Buerger
Associate Editor