CMS Clarifies “Incident to” Billing Relating to Pharmacists’ Services

Recently, the American Academy of Family Physicians (AAFP) sent a letter to CMS Administrator Marilyn Tavenner, with questions regarding physician billing for “incident to” services, specifically whether such rules applied to situations in which a pharmacist employed by a medical practice engages with patients. Some of the pharmacist services include a review of patient history and medications, patient education and counseling, and adherence monitoring.

In the letter, AAFP cited 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…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.

In the Agency’s response, CMS concurred with the AAFP’s assessment, stating, “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.”

Administrator Tavenner also 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, CMS clarified that MTM services, as defined by CPT codes 99605 through 99607 are excluded from Medicare Part B coverage and therefore not subject to “incident to” requirements.

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