Week 16: SBAS (Westburg)

What are the major pharmacist/pharmacy compensation framework?

- medication reimbursement/business incentives

- MTM services

- payment for services (E/M)

- unique pharmacy services (e.g., med sync, packaging)

What are examples of challenges in medication reimbursement and business incentives?

DIR fees and clawbacks, 340B changes, MAC pricing issues, and lack of strong incentives

Why are MTM services difficult to sustain financially?

not all payers cover MTM, definitions vary by plan/region, and reimbursement is inconsistent

What are unique pharmacy services that may generate revenue but not via MTM/E/M?

med sync, compliance packaging, and other individualized services (varies by pharmacy and payer)

Why is provider status important for pharmacists?

Determines the ability to bill medical plans

Medicare requires federal legislation, Medicaid depends on state law, and commercial plans decide individually

What distinguishes medical billing from pharmacy billing in process flow?

medical billing → EMR → health plan with slower processing

pharmacy billing → PBM → instant adjudication

What fee-for-service payment structures?

CPT codes, MTM codes, E/M codes, targeted service codes, facility fees

What value-based payment structures?

pay-for-performance, bundled payments, shared savings, risk-based contracts, and capitation

What infrastructure considerations differ across practice settings (community pharmacy, clinic/health systems, FQHC/RHC)?

- community pharmacies need software for medical billing plus contracting/credentialing systems

- clinics use existing EMR billing systems

- FQHC/RHC may use PPS encounter-based billing

HCPCS

Healthcare Common Procedure Coding System

What is HCPCS Level I vs Level II?

Level I = CPT (5-digit numeric)

Level II = supply/service codes (letter + 4 digits

In billing, what do HCPCS, ICD-10, and NPI/TIN each represent?

HCPCS = what service

ICD-10 = why (diagnosis)

NPI/TIN = who provides service

What are key characteristics of CPT codes?

AMA-maintained, uniform service descriptions, 5-digit, code existence ≠ payment guarantee, eligibility for billing varies by profession

What is the first step in the billing process?

define the service being rendered

What is Comprehensive Medication Management (CMM)?

as tandard ensuring each medication is appropriate, effective, safe, and taken correctly for each patient's conditions

What components are required for Medicare Part D MTM?

annual CMR + quarterly TMRs, with a written summary, med list, and patient to-do list

99605

New Patient , first 15 min

99606

Established patient, first 15 min

99607

each additional 15 min

What factors drive MN Medicaid MTM crosswalk levels?

# of meds, # of MTPs, complexity, and time requirements

How do you bill a 29-minute established patient MTM visit with 12 meds and 2 MTPs?

99606 + 99607 + 99607

3 multiple choice options

What defines E/M service billing?

increasing complexity levels based on total time or medical decision making (MDM)

What are the two ways to select an E/M code?

based on total time OR medical decision making

What are the four levels of medical decision making?

straightforward, low, moderate, high

Straightforward

99202/99212

Low

99203/99213

Moderate

99204/99214

High

99205/99215

What three components determine MDM?

problems, data, and risk

What is the time range for new patient E/M codes 99202-99205?

15-29, 30-44, 45-59, 60-74 minutes

What is the time range for new patient E/M codes 99212-99215?

10-19, 20-29, 30-39, 40-54

What E/M code applies to a 47-minute new patient visit?

99204

3 multiple choice options

What is the E/M code for a 15-minute established patient visit?

99212

3 multiple choice options

What is a key difference between E/M billing and MTM billing?

E/M uses the same codes as other HCPs but requires copays

MTM may avoid copays but is less consistently covered

What is "incident-to" billing?

billing under a physician's supervision; pharmacists typically only bill 99211 unless state/payer allows higher levels

What types of targeted service CPT codes can pharmacists bill?

transitional care, CGM start/interpretation, chronic care management, diabetes education, annual wellness visits

Which preventive counseling codes correspond to 15 minutes?

99401

Which preventive counseling codes correspond to 30 minutes?

99402

Which preventive counseling codes correspond to 45 minutes?

99403

Which preventive counseling codes correspond to 60 minutes?

99404

What chronic care management codes cover physician/qualified practitioner time?

1. 99424-99425

2. 99491-99437

What chronic care codes involve clinical staff time directed by a physician?

1. 99426-99427

2. 99487-99489

3. 99490, 99439

What is CPT 98960-98962 used for?

patient self-management education using standardized curriculum (individual or group)

What is CPT 96372 used for?

billing for injection administration (intramuscular or subcutaneous)

What are examples of other areas with specific billing codes pharmacists may use?

anticoagulation, COPD/asthma, CKD, CHF, obesity counseling, hypertension, mental health, HIV prevention, naloxone, contraception prescribing

Why is follow-up essential in billing processes?

to manage denied claims, handle audits, and continuously improve revenue processes

What is pay-for-performance (P4P)?

a value-based model linking financial incentives to quality metrics, best practices, and patient satisfaction

How do value-based payment strategies vary across practice settings?

Community pharmacies may initiate payer contracts; clinics coordinate through contracting departments; FQHCs must follow state-specific rules

Which of the following describes an advantage for pharmacists to use Evaluation and Management CPT codes to bill for patient care services?

These claims are the same used by other health care providers, including physicians and nurse practitioners.

3 multiple choice options

Which of the following is an example of value-based payment?

A network of community pharmacies will be paid a bonus incentive if 60%

of the Type 2 diabetes population achieves an A1C of <7% in a year

3 multiple choice options

What four domains interact to define pharmacist practice authority?

1. Scope of Practice

2. Standard of Care

3. Provider Status

4. Payment for Services

How does the Federation of State Medical Boards define "scope of practice"?r

rules, regulations, and boundaries allowing a trained practitioner to practice, governed by continuing education and professional accountability

What major activities are included in Minnesota's statutory definition of the practice of pharmacy?

interpreting/evaluating prescriptions, compounding, labeling, dispensing, clinical monitoring, C-LIA waived tests, drug/device selection, drug administration, regimen reviews, and CPA-based therapy management

What is Standard of Care regulation?

a regulatory model where pharmacists practice to the level consistent with their education, training, experience, and setting, judged by peers under similar circumstances

Which states currently use Standard of Care regulation for pharmacy?

Idaho, Alaska, Iowa; California's version effective 2026

What is a key difference between Standard of Care and Bright Line regulation?

Bright Line regulation uses explicit, objective, specific rules

Standard of Care uses professional judgment evaluated case-by-case

What is an example of Bright Line regulation from pharmacy?

pharmacists must complete 15 CE hours each calendar year (Idaho example)

Why is Standard of Care considered more flexible than Bright Line rules?

it adapts to evolving practice guidelines, tech changes, and expanding pharmacist training without needing constant statutory updates

How does "entry barrier vs. legal ceiling" explain scope of practice?

Minimum competency sets the entry barrier; the legal ceiling may limit pharmacists from practicing to their individual training, which Standard of Care looks to correct

What are the two types of collaborative prescribing agreements?

patient-specific CPA and population-specific CPA

What defines a patient-specific CPA?

a signed agreement for each patient involving the patient, provider, and pharmacist; typically for chronic disease management

What defines a population-specific CPA?

agreement between provider and pharmacist allowing services for broad patient groups regardless of prior provider-patient relationship

What are the two types of Autonomous Prescribing?

Statewide Protocols and Unrestricted (Independent) Authority

What does Independent Prescribing allow pharmacists to do in Minnesota?

independently prescribe opioid antagonists, nicotine replacement therapy, self-administered hormonal contraception, and HIV PrEP/PEP (starting 2026)

How is a Collaborative Practice Agreement defined in federal literature?

an agreement allowing pharmacists to assume responsibility for assessments, ordering labs, and initiating, modifying, monitoring, and adjusting drug regimens under a defined protocol

What does Minnesota statute require pharmacists to do when making therapy changes under a CPA?

document changes and notify or report them to the practitioner responsible for patient care

What historical milestone in 1952 shaped pharmacist practice limitations?

APhA Code of Ethics prohibited pharmacists from discussing therapeutic effects or drug composition with patients

When did Minnesota adopt pharmacist CPA authority?

around 1999

What is Provider Status in pharmacy?

recognition by a payer that a pharmacist can bill for and be reimbursed for healthcare services

Why is Medicare Part B provider status difficult to achieve for pharmacists?

it requires federal legislation to amend the provider list

What was the significance of Minnesota Medicaid covering MTM starting in 2006?

minnesota became one of the first states to reimburse pharmacists for MTM services, defining pharmaceutical care in statute

What 2024 Minnesota law expanded pharmacist coverage beyond MTM?

health plans must reimburse pharmacists for services within their scope if they reimburse physicians for the same services (effective Jan 1, 2025)

What types of targeted services might now be reimbursable under Minnesota's 2024 legislation?

vaccine assessments, strep test-and-treat, hormonal contraception prescribing, and other focused clinical services within pharmacist scope