Billing Gaps Devalue the Patient Care Clinical Pharmacists Provide

Pharmacists in primary care are delivering complex, high-value patient care every day, but a systemic lack of billing means that work is going largely unrecognized and unreimbursed, according to a study in the Journal of the American Pharmacists Association.¹

“The harsh reality is that pharmacists are not signing on as covered providers and billing for their services when they have the authority and opportunity to do so,” writes the American Pharmacists Association (APhA).² “It is time for our profession to lean into the opportunities in front of us and take advantage of them. It is time for all of us to lead where we are planted and grab ahold of the opportunity.”

In a recent study conducted within an academic primary care network, researchers utilized a groundbreaking complexity billing tool to reveal a staggering gap between the high-level clinical services pharmacists provide and the actual revenue they generate. The implementation of this tool, which aligns with the 2021 American Medical Association Medical Decision-Making Criteria, uncovered that approximately 50% of pharmacist visits were significantly underbilled due to existing payer restrictions.¹

This mismatch means that although clinical pharmacists are managing medically and socially complex patients, they are often forced into incident-to-billing models that default to the simplest level of care and the lowest possible reimbursement. The study found that actual reimbursement was 39% lower than the level of service delivered, while the average work relative value unit (wRVU) was 0.45 points lower than what the actual complexity of the care warranted.

READ MORE: Pharmacists Discuss Redesign Workflow as Medical Billing Becomes the Future of Patient Care

The root of this systemic devaluation lies in the Social Security Act, which does not recognize pharmacists as health care providers, effectively barring them from billing Medicare Part B directly for clinical services. Instead, pharmacies are often restricted to narrow specialty codes, such as Specialty 73 for mass immunizers or Specialty A5 for hemophilia supplies, which carry heavy limitations and prevent billing for drugs administered incident to a physician’s service.^1,3

As leadership from the APhA noted, even though 36 states have passed laws mandating some form of pharmacist coverage, the actual billing remains stagnant due to the complex administrative hurdles of provider enrollment and credentialing through agents like the Council for Affordable Quality Healthcare.²

Despite these financial barriers, the clinical impact of pharmacist integration is undeniable, as evidenced by a large-scale evaluation in British Columbia where pharmacists identified over 30,000 drug-therapy problems and were viewed by interprofessional team members as essential for their specialized knowledge, according to BMC Primary Care.⁴

Interprofessional colleagues in these settings value pharmacists for their ability to be focused on medication issues that busy physicians may miss. In transitional care management (TCM), research shows that pharmacist-led post-discharge phone calls enable providers to bill for higher-complexity TCM visits versus standard office visits, generating an average of $211 per visit compared with $106 for non-pharmacist staff calls.^4,5

According to the Journal of Primary Care & Community Health, this involvement not only optimizes reimbursement for the physician practice but also lowers the 30-day readmission rate to 8% compared with 12% for those contacted by other staff.⁵

The financial stakes for the future of the profession are immense, as medical billing can generate a 5-to-9-fold higher profit margin than traditional product dispensing. Successful medical billing requires a technical shift from national drug code-based claims to the complex world of CPT and HCPCS codes that describe specific clinical services.⁶

Although federal recognition of provider status remains stalled, experts urge pharmacists to leverage their clinical scope by utilizing pandemic-era flexibilities—such as real-time telecommunications for direct supervision—and participating in specialized ambulatory models, like heart failure care.

The mismatch between the complexity of pharmacist-provided care and accepted billing codes underrepresents the profession’s cognitive workload and leaves significant financial opportunities on the table.¹

Standardized tools that track complexity are now essential equalizers for discussing workload and value with health system leadership. By quantifying pharmacists’ contributions in the familiar wRVU language used by other providers, the profession can better advocate for expanded billing privileges, justify resource allocation, and ensure the sustainability of clinical pharmacy services.

“This project showed a misalignment between the complexity of care provided by embedded pharmacists in primary care and what is currently billable under existing payer restrictions,” concluded the authors of the current study.¹ “As health care continues to evolve towards value-based models, tools like the complexity score may play a crucial role in accurately representing and valuing the complex work performed by pharmacists in various clinical settings.”

READ MORE: Navigating the Pharmacist Vaccine Reimbursement Paradox

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REFERENCES

1. Marshall K, Leupold S, Grandominico JM, et al. Integration of a complexity billing tool to evaluate unrealized pharmacist revenue and productivity in an academic primary care network. JAPhA. March 30, 2026:103108. https://doi.org/10.1016/j.japh.2026.103108

2. Pharmacists: We must accelerate billing for services. News Release. American Pharmacists Association. September 3, 2024. Accessed April 17, 2026. https://www.pharmacist.com/APhA-Press-Releases/pharmacists-we-must-accelerate-billing-for-services

3. Billing and coding: billing limitations for pharmacies. Centers for Medicare & Medicaid Services. Accessed April 17, 2026. https://www.cms.gov/medicare-coverage-database/view/article.aspx

4. Nemir A, Salil A, Kapanen AI, Zed PJ. Unpacking the value of pharmacists in team-based primary care in British Columbia, Canada: a qualitative evaluation. BMC Prim Care. 2025 Dec 9;27(1):58. doi: 10.1186/s12875-025-03131-2.

5. Meier M, Simpson G, Patel M, Keedy CA. Impact of Pharmacist Integration Into Primary Care on Reimbursement for Hospital Follow-Up Visits. J Prim Care Community Health. 2023 Jan-Dec;14:21501319231174768. doi: 10.1177/21501319231174768.

6. Nowosielski B. The untapped clinical revenue pharmacists can uncover through medical billing. Drug Topics. April 2, 2026. Accessed April 17, 2026. https://www.drugtopics.com/view/the-untapped-clinical-revenue-pharmacists-can-uncover-through-medical-billing-apha-2026