Mastering Pharmacy Medical Billing + Claims Submission
A comprehensive guide to medical billing, claims submission, and revenue cycle management for pharmacy clinical services. Learn the difference between D.0 and medical billing, credentialing requirements, and essential CPT codes.
This in-depth guide includes:
- Overview of pharmacy D.0 vs medical claims comparison
- Payer enrollment and credentialing process walkthrough
- Technology partner selection guidance
- Essential CPT and ICD-10 codes reference chart
- Revenue cycle management process breakdown
- Strategies for overcoming common billing challenges
Strategies for Mastering Pharmacy Medical Billing + Claims Submission
Medical claims submission involves utilizing Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes to represent the services provided by pharmacists accurately. These codes are how physicians, nurse practitioners, and other providers bill for services.
This guide walks you through establishing a solid foundation for medical billing, including payer enrollment, credentialing, selecting technology partners, and training your staff. You'll learn how to identify reimbursable services, evaluate service demand in your community, and align your services with payer requirements.
The credentialing process typically takes 2-4 months and requires education verification, licensure, experience documentation, malpractice insurance, and background checks. Tools like CAQH ProView can streamline this process by allowing you to maintain one profile shared with multiple payers.
By mastering medical claims and revenue cycle management, you can expand pharmacy revenue on the clinical services you already perform—without the DIR fees associated with traditional pharmacy benefit manager billing.
Frequently Asked Questions
D.0 billing goes through Pharmacy Benefit Managers (PBMs) for prescription medications using National Drug Codes, while medical billing uses CPT/HCPCS codes and goes directly to health plans for clinical services like immunizations, MTM, and comprehensive medication reviews. Medical billing typically offers higher reimbursement rates and no DIR fees.
Typically 2-4 months. The process includes verifying education, licensure, experience, training certifications, malpractice insurance, and background checks. Use CAQH ProView to streamline the process by maintaining one profile shared with multiple payers.
Common codes include 90460-90474 for immunization administration, 99605-99606 for medication therapy management (MTM), and E/M codes like 99202/99212 for acute care visits including test-to-treat, smoking cessation, PrEP, and PEP services.
Reimbursable services include medication therapy management (MTM), immunizations, acute and chronic care services (test-to-treat, smoking cessation, wellness visits), comprehensive medication reviews, point-of-care testing, and health screenings.
Common challenges include coding errors, claim submission errors, and payer denials. Avoid these by employing coding references, submitting claims promptly, maintaining thorough documentation, and appealing denied claims with proper justification.
Ready to dive in?
Download the complete guide and start implementing these strategies today.