Incident-To Billing for Pharmacist Services

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Some pharmacists will find themselves working in an ambulatory clinic or other setting that provides an opportunity to bill payers (namely, Medicare carriers) directly for services provided. The clinical pharmacist to some extent serves as their own manager; however, they will also be managed as per office/administrative functions dealing with revenue generation by a physician or other supervising pharmacist under the auspices of a physician. One of the primary means of performing billable services is through so-called ‘incident-to’ billing where the pharmacist provides services incident to, or in other words in support of the physician, such as follow-up education, lifestyle management, and medication therapy management. While a nice opportunity for pharmacists, incident-to billing (‘99211 billing’ named after its approved Current Procedural Technology (CPT) code) is for relatively small amounts of money and can result in considerable administrative overhead costs for the billing provider.

There are a number of misconceptions about incident-to billing, and these are explained by Dietrich and Gums, who in addition also provide excellent tips/strategies for billing pharmacist services.1 First, while 99211 is  most common, there are higher “levels” of billing potentially for pharmacist services, specifically 99213 and 99214 codes, representing more intense services that can be billed at much higher rates, which (at the time of writing this Tip) was right at $22 for 99211 services, yet $110 for 99214. A break-even analysis suggests that 99211 billing requires seeing 122 patients per week to break even on pharmacist services, whereas 99214 billing would require seeing only 26 patients per week. With incident-to billing, the pharmacist must provide services under the supervision of a physician, and the pharmacist services must be appropriately documented. Because the physician is the billing provider, they will receive the associated work relative value unit (wRVU) credit for the visit, which is incentive for some physicians to collaborate with pharmacists under this type of model, since in most settings, physician bonuses are tied to wRVU targets, and collaboration would increase the wRVUs generated by the physician. Physician liability may also be reduced by working collaboratively with a medication expert to ensure that therapeutic treatment regimens are used safely and are monitored appropriately. Collaborative practice arrangements (CPAs) are usually advisable, and their nature or structure will be defined to some extent by state practice laws. They are often helpful in that they reduce the likelihood the physician will have to provide immediate supervision, or be  literally in the same room as the pharmacist when that pharmacist is providing the service. It might also make it easier to bill for higher level (eg, 99213, 99214) services.

Clinical pharmacists must be savvy managers, understanding the costs for their time and the administrative overhead required for their oversight and adjudication of payment for their services. They must also be creative and research ways to work with physicians and office managers to identify ways in which to perform and bill for higher level services that create a win-win with the billing provider.

Additional information about Operations Management and Implementing Value-Added services can be found in Pharmacy Management: Essentials for All Practice Settings, 5e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 5e. If your institution does not provide access, ask your medical librarian about subscribing.

1Dietrich E, Gums JG. Incident-to billing for pharmacists. J Manage Car Spec Pharm. 2018;24:1273-1276.

Shane Desselle

Professor of Social and Behavioral Pharmacy, Touro University California

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Go to the profile of Shane Desselle
about 2 months ago

Incident-to billing sometimes might not even be worth the time and administrative costs associated with it.