Basic terminology in obtaining reimbursement for pharmacists' cognitive services

Abstract

Purpose: A basic overview and definitions of commonly used billing and reimbursement terminology that pharmacists will need to know to obtain reimbursement for cognitive services are provided.

Summary: Currently, the profession of pharmacy has been gathering momentum in its efforts to seek and obtain reimbursement for cognitive services. However, there have been major barriers in seeking reimbursement, including the lack of understanding by third-party payers of the pharmacist's role in patient care and the pharmacist's in-depth knowledge of pharmacotherapy, the lack of appropriate billing codes for pharmacists' services, and the lack of detailed knowledge and understanding by pharmacy practitioners of nondistributive reimbursement mechanisms, processes, and terminology. The types of services provided are usually described by the American Medical Association's Current Procedural Terminology (CPT) codes for the face-to-face provision of patient care services by a pharmacist. As of January 1, 2006, pharmacists have been able to indicate the appropriate diagnosis code from the International Classification of Diseases, 9th Revision (ICD-9) (ICD-10 will replace the ICD-9 on October 1, 2007), and CPT code when billing under a major medical plan that recognizes the pharmacist as a patient care service provider. Understanding the billing and reimbursement terminology will aid pharmacist communication with third-party payers, Medicare, and Medicaid. A glossary of the most commonly encountered terms in billing and reimbursement procedures for cognitive services is provided. Also included are lists of Web-based reimbursement resources and references on reimbursement for cognitive services by the pharmacist.

Conclusion: An understanding of terminology is important in receiving reimbursement for cognitive services.