Billing & Payment Center

Billing & Payment

Traditionally, pharmacist reimbursement has largely been focused on obtaining payment for the provision of products, like prescription medications. Today, pharmacists have an expanded scope of practice and the pharmacy profession has incorporated more clinical aspects into routine patient care, like chronic disease management, care transitions interventions, and medication therapy management. For these clinical services to be sustainable, pharmacists must be able to receive payment for the resources and time dedicated to improving patient care and outcomes.

Currently, pharmacists are not recognized as providers under Medicare Part B and therefore cannot directly bill for most of the clinical services they have been trained to provide. However, through collaborations with other health professionals, state insurers, private insurers and health systems, pharmacists can implement more sustainable clinical programs into their practices.

Our payment resources are designed to help you understand existing and emerging opportunities to be compensated for providing certain patient care services.

Outpatient Fee-for-Service Billing

Access APhA’s billing primer to better understand common billing codes used for billing pharmacists’ services in the current healthcare environment.

Getting Started with Outpatient Fee-for-Service (FFS) Billing

Pharmacists have opportunities to be paid for patient care services but understanding those opportunities can be complicated. Billing Primer: A Pharmacist’s Guide to Outpatient Fee-for-Service Billing offers an introduction to common billing codes and provides a broad overview of factors to consider in billing for pharmacists’ services. This resource contains aggregated information from a variety of sources to help you in understanding billing codes and how they are used. This guide highlights:

Potential payers for pharmacists' patient care services
Important billing codes and how to use them in your practice
Easy-to-reference table with commonly used billing codes

Access the most current billing-related content for pharmacists available today. This resource is free for APhA members.

Join APhA today for free access to this resource and many other benefits of membership.

ACOs/Medical Homes

Access APhA’s new case studies resource on the successful integration of pharmacists in accountable care organizations (ACOs) and medical home models.

Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Emerging value-based payment (VBP) models are changing the way health care is delivered and paid for in the United States. Increasingly, health care providers are compensated for interventions that optimize clinical outcomes. As a result, opportunities for pharmacists to practice at the top of their license and training by delivering patient care services are emerging and expanding.

Developed by the APhA Academy of Pharmacy Practice and Management (APhA–APPM) Medical Home/ACO Special Interest Group (SIG), this resource highlights 10 examples in which pharmacists are successfully integrated into PCMHs and/or ACOs in various practice settings.

Download Report

Chronic Care Management

Our Chronic Care Management resources will help you understand this powerful base payment mechanism opportunity for pharmacists and their prescriber partners who are collaborating on the care of a patient population.

Chronic Care Management

Beginning January 1, 2015, the Medicare Physician Fee Schedule (PFS) reimburses qualified providers for Chronic Care Management (CCM) services for Medicare beneficiaries with two or more chronic health conditions. Pharmacists can participate in CCM as clinical staff, with their services being billed incident to by a qualified provider. CCM services include five core activities:

Recording structured data in the patient’s health record
Maintaining a comprehensive care plan for each patient
Providing 24/7 access to care
Comprehensive care management
Transitional care management.

The Centers for Medicare & Medicaid Services (CMS) estimates that approximately two-thirds of Medicare patients have two or more chronic conditions, and CCM aims to better coordinate the care these patients receive. Through CCM and complex CCM, CMS pays for non-face-to-face care coordination services furnished to Medicare beneficiaries who reside in the community setting that meet the following requirements:

Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; and
Comprehensive care plan established, implemented, revised, or monitored.

CCM could be a powerful base payment mechanism for pharmacists and their prescriber partners who are collaborating on the care of a patient population. Additionally, CCM and complex CCM could provide the fee-for-service mechanism for pharmacists to be compensated for some of their services as pharmacists and physicians enter into emerging quality-based and risk-sharing payment structures.

APhA's CCM Resources

APhA collaborated with two Quality Improvement Organizations, Health Quality Innovators and Delmarva Foundation, to create Chronic Care Management (CCM): An Overview for Pharmacists. This guide describes the requirements for CCM and how pharmacists may play a role as clinical staff.

CCM in Practice. Learn about how Michelle Thomas, pharmacist at Chickahominy Family Physicians in Virginia, has integrated CCM into her pharmacy practice.

The CCM Patient Consent Checklist was created in collaboration with Telligen and can be used to help guide members of the CCM care team as they collect necessary information for patient consent to participate in CCM service.

What Can Chronic Care Management Do for You? - This webinar helps the whole care team learn what CCM is, how pharmacists can engage, and strategies for reimbursement/sustainability. Free CE is available for all clinicians.

Additional CCM Resources

CMS Guidance on Chronic Care Management Services

CMS FAQs on CCM

CMS Summary of CCM Changes for 2017

CMS Connected Care Initiative