KMAP BULLETIN: Pharmacist as Provider – Approved Billable Services
Date: 08/02/23
KMAP GENERAL BULLETIN 23196 (PDF)
Effective with enrollment dates on and after August 1, 2023, Kansas Medicaid will recognize pharmacists as providers and reimburse pharmacies or medical practice groups on behalf of pharmacist’s services that are not directly related to dispensing medications.
Enrollment Requirements for Pharmacists
- Online enrollment application with the pharmacist as “Individual within a Group (IG)” is required.
- An active Kansas pharmacist licensure in good standing with the Kansas Board of Pharmacy is required.
- A Clinical Laboratory Improvement Amendment (CLIA) waiver is an optional requirement for pharmacists.
- Each pharmacist must enroll with their own National Provider Identifier (NPI) (type 1) to provide the covered services with taxonomy code 1835P0018X.
- Pharmacists must be affiliated with a pharmacy or medical practice for the services to be billed to Medicaid. Medical practice groups include Physician (provider type 31) or Advanced Practice Registered Nurse (APRN) (provider type 09) groups.
- With IG enrollment, pharmacists are required to follow current state policy enrollment requirements, related to 42 CFR 455.101.
- Pharmacists will be enrolled with new provider type/provider specialty (PT/PS) 32/276 (Nonphysician/Pharmacist).
Enrollment Requirements for Pharmacies:
- Pharmacies must be enrolled as a Group provider to allow pharmacists to be associated as an IG.
- Pharmacies must follow the existing enrollment requirements to enroll as a Group provider.
- Pharmacies will be enrolled with new PT/PS 32/240 and function as a billing provider for pharmacists. Pharmacies will use the existing taxonomy code 333600000X.
Billing Guidelines:
- The billing provider reported on the claim must be the pharmacy’s (type 2) NPI, or the medical facility’s NPI, and be actively enrolled in Kansas Medicaid to be paid.
- The rendering provider reported on the claim (Line 24J of the Professional Services Form) must be the pharmacist’s (type 1) NPI and they must be actively enrolled in Kansas Medicaid.
- Pharmacies or medical facility groups must bill pharmacist services through the Kansas Modular Medicaid System (KMMS) Provider Web Portal, on a CMS-1500 Professional Claim Form, or ASC X12N 837P transaction, using appropriate HCPCS codes.
- The two-digit national Place of Service (POS) code of 01 (Pharmacy) or 11 (Office) is required on the claim.
Covered Services:
The following services are covered for pharmacist PT/PS 32/276.
Point of Care Testing:
A pharmacist may initiate therapy using the Point of Care Testing codes listed below. A CLIA Testing Waiver is required at the time the service is provided. The State Board of Pharmacy protocols for these services must be followed. The pharmacist’s NPI should be the prescriber on the prescription billed by the pharmacy. Pharmacists will be considered prescribers for prescriptions resulting from performing these protocols. Pharmacists billing these claims as the prescriber must practice strictly in accordance with the State Pharmacy Practice Act. These claims are subject to audit for all requirements needed to provide these services.
| Point of Care Testing | E&M Services |
|---|---|
| 87400 QW | 99202 |
| 87502 QW | 99203 |
| 87651 QW | 99211 |
| 87804 QW | 99212 |
| 87880 QW | 99213 |
| 99214 |
CLIA Waived Testing:
Pharmacies are to have protocols in place for any CLIA Waived Tests that the Laboratory Improvement Program Office of the Kansas Department of Health and Environment (KDHE) laboratories have approved them to do.
| CLIA Waived Testing | |
|---|---|
| 80061 QW | 86780 QW |
| 81003 QW | 86803 QW |
| 82465 QW | 87389 QW |
| 82947 QW | 87635 QW |
| 83036 QW | 87811 QW |
| 83037 QW | 87889 QW |
| 86618 QW | 82962 |
| 86701 QW | 81002 |
Reimbursement:
The covered services will be reimbursed same as other mid-level practitioners, at 75% of Medicaid rate.
Audits/Edits/Limitations:
All codes listed will have the same audits/edits/limitations that these codes currently have or change to in the future. The provider is to follow all current provider documentation requirements.
Note: The effective date of the policy is August 1, 2023. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.