In 1998 a family practice physician in Columbus, Ohio, asked me to help manage an uncontrolled type 2 diabetes population. The practice invited United Health Care (UHC) officials to visit to determine requirements for documentation; collaborative interaction between the pharmacist, physician, and patients; and appropriate billing with Evaluation and Management (E&M) codes. We were told to follow the Marshfield Clinic guidelines for documentation and the Medicare definitions for the selection of the appropriate CPT codes for the services rendered.
In 2004 we invited the CMS Region V team to evaluate and possibly endorse to CMS in Baltimore what we were doing; we hoped to see pharmacists approved as providers recognized by CMS.
The group of administrators, physicians, and lawyers came and spoke with our patients and the clinical team about the services rendered and results achieved by our collaborative practice. At this point we had put nearly 275 patients on the service.
In 2007 the practice decided to stop taking Medicaid patients and the number of patients dropped to about 150.
The three elements of physician practices upon which you do not want to intrude are:
- Space. The more space you take up, the less space the physician is able to move patients into.
- Time. Be mindful of how much time you require of physicians. Even though you are generating income, their perception will be that they could be earning more money in the time you are asking of them.
- Money. Physicians are generally averse to sharing any income for which they have to do the billing. And pharmacists cannot directly bill for services. You see the problem.
A search for the right space
In 2008 the practice no longer wished to continue the clinical pharmacy program it had established for the management of diabetes/metabolic syndrome. I was forced to find new locations in which to see patients. I split my practice between two sites, taking with me about half the patients left on my service.
After one year, one of the offices went out of business and I was left with a site I visited once a week. Three years later, that practice was sold to an urgent care center group and I was once again forced to relocate.
I moved to a family medicine site within the same geographic area. After I had practiced three weeks at the new site, the doctor, who had consulted the medical bill coder, informed me that he could not bill as he had been doing for the previous 13 years. He also told me to find a new site; I could stay and see patients, but I could collect only co-payments. After three more months, he told me he would not pay me at all, not even co-payments.
Eventually I was able to move into a site that was part of a physician network. I was able to move only 50 patients with me. I built up my service over the next two years to about 150 patients. This also included a group of patients for nonnarcotic pain management.
Again the coders interfered and made the same claim — that, concerning pharmacists, incident-to billing was limited to the $19 code of CPT 99211. After 17 months during which I had encountered no real problems, my salary was reduced by 75% and I was told that if I could produce documentation to refute the coders’ claim, I could be reinstated.
After three months at the reduced rate, I was furloughed from employment completely.
About six weeks later, I received documentation from CMS establishing that the coders had not been correct. Marilyn Tavenner, who was then administrator of CMS, issued a letter to the AAFP, stating that these types of collaborative services could have a range of billing codes (E&M) 99211-99215.
I produced the documentation, including the citation in the Federal Register showing that the coders were incorrect. The end result was that the doctors declined to re-engage me. They had my patients and the treatment protocols I had created for those of their patients who had previously failed to reach clinical goals.
A happy landing?
I have now moved into a private practice of family medicine. I was able to bring about 40 patients with me.
In 2007 a business partner and I developed algorithms for treatment of several chronic diseases into a software program (CeutiCare ICG) that we now offer for commercial use. Armed with the affirmative guidelines for incident-to billing as it relates to pharmacists working collaboratively with physicians, I hope I have reached the end of professional disruption.
If you wish to work as a clinician in a space where others do not see you, you have to stand your ground — and have a clinical (software) system that will back you up.
Provider status, either state-by-state or through CMS, must occur.
Even if H.R. 592 and S. 314, the current Congressional bills, are passed, their restriction to medically underserved areas will jeopardize pharmacists’ chances for payment, since that will depend on the zip code in which the patient resides. If the patient moves into a different part of the same county, for example, pharmacists may not be able to continue to bill for services rendered. This gives a new meaning to the words “at risk for payment.”
I hope to be able to report over the next year that life has become less stressful.