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Pharmacists Hope to Bill Under New Medicare ‘G’ Code

Pharmacy & Therapeutics...November 2012

Payment Would Be for Transitional Care After Hospital Discharge
Stephen Barlas


Will Medicare lock out pharmacists from its new post-hospital transitions payment program? That is not clear yet, and may not be for some time, although the Centers for Medicare and Medicaid Services (CMS) says it will establish a new "G" code for such payments in calendar 2013.

The new G code is the latest step by Medicare to tamp down on hospital readmissions, many of which are preventable, and all of which cost the federal government billions of dollars. In its 2007 Report to Congress: Promoting Greater Efficiency in Medicare, MedPAC, the quasi-government advisory group, found that, in 2005, 17.6 percent of admissions resulted in readmissions within 30 days of discharge, accounting for $15 billion in spending. MedPAC estimated that 76 percent of the 30 day readmissions were potentially preventable, resulting in $12 billion in spending. In the same report, MedPAC also found that the rate of potentially avoidable rehospitalizations after discharges from skilled nursing facilities was 17.5 percent in 2004.

The Medicare program has been increasingly concerned about preventable readmissions ever since the MedPAC report, as has Congress, which is why the Affordable Care Act (ACA) included a number of programs aimed at reducing readmissions, generally through smoothing the transition of a patient from hospital to home. We have written about a number of these programs, including the Partnership for Patients and Community-based Care Transitions Programs.

Now Medicare is upgrading further its incentives for post-hospital transitions care by establishing this new Healthcare Common Procedure Coding System (HCPCS) G-code. Typically, hospital physicians and docs in skilled nursing homes bill Medicare using Current Procedural Terminology (CPT) codes when they discharge a patient. So for example, there are hospital discharge management codes (CPT codes 99238 and 99239) and nursing facility discharge services (CPT codes 99315 and 99316) which capture the care coordination services required to discharge a beneficiary from hospital or skilled nursing facility care. The work relative values for those discharge management services include a number of pre-, post-, and intra-care coordination activities. But the full gamut of "post-care" services such as lifestyle adjustments and medication reconciliation and adherence lie outside what those discharge codes describe.

Theoretically, the patient's community primary care physician should be responsible for medication reconciliation, etc. But the CPT office visit codes the physician bills for a recently discharged patient only cover what are called "evaluation and management" services. They typically do not include the kind of services centered around easing a patient's transition into her home, and assuring everything is done to maintain her ostensibly stabilized post-discharge condition so that she does not have to go right back to the hospital or nursing home.

The transition services encapsulated in this new G code include reviewing a patient's medical record and his diagnostic test results, evaluating psychosocial status and adjusting a plan of care. The CMS envisions that these services would be provided with the physician or nonphysician not necessarily having to see the patient, as is the case with a physician billing an E&M code. So it follows, one would think, that the G code will be billed by someone other than a physician.

Moreover, the transition services laid out in the G code--one could argue they are the key services in the G code, with regard to preventing readmission--include things that a pharmacist is best able to do, such as an assessment of a patient's understanding of the medication regimen and undertaking medication reconciliation and providing medication therapy management.

Moreover, the kinds of nonphysician providers hospitals would like to see eligible to billing G codes, people employed by the hospital, clearly do not have the expertise to perform the medication tasks. These are job descriptions such as medical assistants, care navigators, social workers and “health coaches” who, the American Hospital Association, "are often the team members telephoning patients to assist with follow-up appointments, prescription refills, insurance inquires and numerous other social issues."

"NCPA contends that community pharmacies are already performing many of these transitions of care related activities and should be compensated for them, specifically medication reconciliation," says John M. Coster, Ph.D., R.Ph., Senior Vice President of Government Affairs, National Community Pharmacists Association (NCPA). "CMS currently recognizes community pharmacies as a provider under certain circumstances as pharmacies currently have the ability to bill G codes for a limited number of services. CMS should allow pharmacies who participate in the Part B program to bill for transitional care management services that involve medication therapy."

So it would seem that Medicare might explicitly designate pharmacists as among the "physicians or qualified nonphysician practitioners" eligible to bill the new G code. The proposed rule issued this past summer does not do that.

With that wiggle room in mind, the American Pharmacists Association wants the CMS to consider if it is necessary to create a different new G-code to accommodate post-discharge transitions of care services provided by a pharmacist, especially when a pharmacist is working in or contracting with evolving integrated patient care models (including patient centered medical homes and accountable care organizations) and community pharmacy settings.