PA Pharmacists Billing Ability Expanded
On March 1st, 2024, the Pennsylvania Department of Health Services will allow pharmacists to register with the Pennsylvania medial assistance program which will enable them to provide services and bill Pennsylvania medical assistance.
The detailing of this expansion is remarkably similar to the current provider status the PA DHS recognizes with physician assistance with regards to billing for PA MA services. The direct coding for the credentials within the PA MA program will share the 100-level distinction but will come with its own individual billing code modifier for pharmacy services. Enrollment will occur online at promise.dpw.state.pa.us. Attempts at enrollment prior to the 3/1/24 launch will be rejected. Some important enrollment information is that the process of enrolling individual pharmacists with PA DHS will require them to obtain a NPI number prior to enrollment. There is a distinction between fee for service billing and bundled billing in the enrollment so please pay attention to your site’s requirements. In addition, the registering pharmacist must enroll separately for each site of care they will be billing services from. Currently there is no fee for registering and the enrollment will last for 5 years before needing to be renewed. There will also be the ability to bundle compensation fee with the locations services rather than receiving the payment directly.
Do note that these services must be within the scope of practice of a pharmacist, although it is considered a provider status recognition of a midlevel practitioner, this will not enable any prescribing, diagnostic, or diagnosing powers. Pharmacy services in Federally Qualified Health Centers or Rural Health Clinics are not applicable to this fee system and should bill under T1015 for their PPS. Managed Care Organizations have different billing codes and procedure than the PA DHS but are require providing coverage for the same services. Pharmacists would have to register with those MCOs separately in order to bill for services provided.
Per PA DHS Medical Assistance Bulletin 10-24-02, pharmacists will be enrolled as Provider Type 10, Specialty Code 247, Specialty Code Description of Pharmacist. Note that Provider Type 10 also covers Physician Assistants so be careful when enrolling. Those Pharmacists already enrolled with the PA MA program under the PT:24/SC:247 will have their enrollment automatically adjusted to PT:10/SC:247. If a pharmacist has the PA DOH Tobacco Cessation Counseling Certification, they will also have an additional SC:370 (Tobacco Cessation) added to their PT:10 provider file.
There are also announced set PA MA program Fee Schedule available for the pharmacy services provided under the new practitioner program. Per PA DHS 54 Pa.B 699 (published Feb 10 2024) in accordance with 55 Pa Code § 1150.61(a) there are four added procedure codes (99408, 99605, 99606, and 99607) as well as two deletions (90471 and 90472). 99408 refers to Alcohol and non-tobacco substance screening and brief intervention of 15 to 30min, resulting in a MA fee of $24.93. 99605 refers to MTM provided by an individual pharmacist who is face to face with a patient 15min initial visit, resulting in a MA fee of $44.80. 99605 refers to MTM provided by an individual pharmacist who is face to face with a patient 15min follow-up appointment, resulting in a MA fee of $29.18. 99607 refers to MTM provided by an individual pharmacist who is face to face with a patient for each additional 15min block (this is to be billed in addition to the primary service code), resulting in a MA fee of $27.96. The removed codes of 90471 and 90472 are the previous pharmacy administration codes for vaccines and multiple vaccines, the new MA fees for vaccinations will follow the current MA Program Fee Schedule which specific for most vaccines. Per the DHS Medical Assistance Bulletin 01-24-01, 08-24-02, 10-24-03, 24-24-01, 31-24-02 that pharmacists will also be able to bill for additional vaccine counseling, diabetic counseling, and specimen collection that were billable by other mid-levels. There is also a Waiver Program Exception process for when a provider determines that a MA patient may need services that are in excess of the limited established by the MA Program Fee. This can be accomplished via the MA 97 Outpatient Services Authorization Request Form at the PA DHS website.
The importance of this distinction is important and welcome for pharmacists in Pennsylvania. Where now they can bill for complex services that they previously provided and were unable to bill for as they were not considered providers in Pennsylvania. Unfortunately, there services will remain uncompensated for Medicare patients as the federal government does not consider pharmacists as providers. This also mindful of the concept of medical scope creep. Many tradition prescribers such as MD's and DO have been vocal about prescribing scope creep with medical duties and the erosion of traditional lines. This step does not encroach on any perceived duties as it only enables pharmacists to bill for services that they have traditionally provided, of note that pharmacists have been legally allowed to administer and bill for immunizations for many years.
This expansion has the ability to help bolster pharmacy financial security especially in the local setting where pharmacy services are eroding, and patient access is decreasing due to lowered compensation of direct dispensing. This expanded income source may help independent pharmacies stay open and also expand pharmacist footprint in nontraditional areas to improve overall patient health. As this service rolls out the next step is to encourage recognition federally so the services can be standardized and enshrined.
References
PA Pharmacists Provider Status – Medical Assistance. Pennsylvania Pharmacists Association. https://www.papharmacists.com/page/PAProviderStatus_MA
Pennsylvania Department of Human Services. Medical Assistance Bulletin 10-24-02 Pharmacist Enrollment in the Medical Assistance Program. (2024, February)
Pennsylvania Department of Human Services. Pennsylvania Bulletin, Volume 54, Issue 6 54 Pa. B. 699. Medical Assistance Program Fee Schedule: Procedure Code Additions and Deletions for Pharmacist Services (2024, February)
Pennsylvania Department of Human Services. Medical Assistance Bulletin. 01-24-01, 08-24-02, 10-24-03, 24-24-01, 31-24-02. Medical Assistance Program Fee Schedule: FFS Pharmacist Billing Procedures. (2024, February)
Pennsylvania Department of Human Services. Provider Enrollment Training for Pharmacists. Thursday February 15 2024.