AAFP, CMS Clarify 'Incident to' Rules Relating to Pharmacists' Services

April 16, 2014 02:01 pm News Staff

The complexity of Medicare billing regulations can baffle even the most business-savvy family physician. So recently, when the AAFP and family physician members had questions regarding Medicare rules for billing "incident to" services, the Academy went straight to CMS Administrator Marilyn Tavenner, M.A., for answers.

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According to Kent Moore, the AAFP's senior strategist for physician payment, the incident to rule allows a physician to bill for some health care services provided by practice staff members as long as those services are part of the patient care plan already established by the physician and as long as certain other requirements are met.

For example, if a patient returns to the practice for a blood pressure check following a weeklong trial on a new blood pressure medication initiated during a prior physician-patient encounter, the return visit can be handled by a nurse and potentially billed to Medicare under the physician's name as an incident to service.

Questions arose as to whether incident to rules apply to situations in which a pharmacist employed by the physician's practice also engages with patients.

In a Jan. 22 letter to Tavenner, Moore noted family medicine's increasing emphasis on team-based care and the patient-centered medical home model. "To that end … family medicine practices are employing pharmacists as part of the care team," wrote Moore. "Pursuant to a plan of care created by a physician in the practice and incidental to services provided by the physician, these pharmacists are having and documenting direct (face-to-face) encounters with patients," he noted.

Story highlights
  • The AAFP worked with CMS to confirm certain regulations pertaining to "incident to" services provided to Medicare patients.
  • Specifically, the Academy had questions regarding whether incident to rules apply to certain situations in which a medical practice-employed pharmacist engages with patients.
  • CMS agreed with the AAFP that if all of the requirements of the incident to statute and regulations were met, a physician could bill for services provided by a pharmacist as incident to services.

Those services include a review of applicable patient history and medications and counseling regarding the risks and benefits of pharmaceutical treatment options, as well as instructions for improving pharmaceutical treatment adherence and outcomes.

Moore noted that such services, if provided directly by the physician, would likely be coded and billed as an evaluation and management service.

He listed the four basic Medicare rules that qualify services as incident to along with the definition of "auxiliary personnel" as defined by in sections 60(A) and 60.1(B) of the Medicare Benefit Policy Manual.

"We (the AAFP) cannot find anything in section 60 that would exclude pharmacists from this definition," said Moore. "Accordingly, we are inclined to think that physicians may bill Medicare for a Part B covered service provided by a pharmacist in the practice as long as all of the incident to rules are otherwise met.

"However, before advising our members accordingly, we wanted to confirm this interpretation with you," he added.

In a written response to Moore, Tavenner said, "In your letter, you ask that we confirm your impression that if all the requirements of the 'incident to' statute and regulations are met, a physician may bill for services provided by a pharmacist as incident to services.

"We agree," she noted.

However, Tavenner pointed out that in conjunction with the 2014 Medicare physician fee schedule, CMS modified the sections of the regulations pertaining to the definition of auxiliary personnel and the provision of services and supplies to state that all applicable state laws also must be observed.

Lastly, Tavenner confirmed Moore's understanding that medication therapy management services -- as described by CPT codes 99605 to 99607 -- are not subject to incident to billing requirements. Such codes are excluded from Medicare Part B coverage and may only be reimbursed by a beneficiary's Medicare Part D or Medicare Advantage plan.

Related AAFP News Coverage
Release of Final 2014 Medicare Fee Schedule Elicits AAFP Summary

More From AAFP
Summary of 2014 Medicare Physician Fee Schedule(27 page PDF)

Coding Information

Additional Resource
CMS Medicare Learning Network: MLN Matters article: "'Incident to' Services"(www.cms.gov)