Use of New CPT Codes Depends on Practice Arrangement

Cheryl A. Thompson

Am J Health Syst Pharm. 2005;62(19):1956-1966. 

In This Article

Hospital's Antithrombosis Clinic

Since 2003, Thomas S. Sisca has billed Medicare and other third-party payers for his anticoagulation monitoring and management services as clinic visits, not physician visits, through Maryland's Memorial Hospital at Easton, part of Shore Health Systems.

"I don't think we're breaking even," he said, but the hospital-based clinic has been collecting enough payments to increase the number of full-time-equivalent pharmacists to 2, up from 1.5, and open enrollment to outpatients on October 1 (see sidebar on page 1964).

According to Randy Booze, who provides Sisca with budget and reimbursement information, the antithrombosis clinic collects 94% of charges to Medicare and Medicaid and 98% of charges to commercial insurers and health maintenance organizations.

But this happens only because the hospital is in Maryland, the only state with an "all-payer" hospital rate-setting system, Booze said.

Maryland's Health Services Cost Review Commission (HSCRC) establishes rates for services provided at acute care general hospitals in the state, he said. Private third-party payers must pay a state-set percentage of those rates for covered services, and, under a waiver from the federal government, Medicaid and Medicare pay a certain percentage of state-established charges for services delivered to those programs' beneficiaries.

Booze said that Sisca's clinic collects more money per patient this year under the Maryland all-payer system than the clinic would if located in another state.

But Maryland and the federal government change their rates each year. Booze said that Sisca's clinic may not have a locale advantage in the future.

Sisca said that the Maryland HSCRC allows him and the other pharmacist to bill for anticoagulation services delivered at the hospital-based clinic.

"We have essentially an initial and a follow-up clinic visit," Sisca said, referring to CPT codes 99201 and 99211, respectively.

Booze said that, for Sisca's services, Shore Health set the number of RVUs for each clinic visit at six, with each Maryland-based clinic RVU generally equal to five minutes.

Changing the CPT codes used by the antithrombosis clinic would not affect the size of the payments received for Sisca's services, Booze said, because the state sets the payment rates. But changing the number of Maryland RVUs associated with Sisca's services would.

Maryland's all-payer hospital rate-setting system has meant that Sisca has not had to negotiate payment structures with third-party payers.

But, he said, two health maintenance organizations have refused to pay Memorial Hospital for the clinic's services, declaring that pharmacist-provided anticoagulation monitoring and management is unnecessary and that physicians should perform an equivalent service as part of the office visit.

"Maybe 5% of our referrals have been transferred back to the physician due to financial issues," Sisca said.

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