Challenges and outcomes of pharmacist billing and revenue in a hospital-based primary care setting.

BACKGROUND

Embedded ambulatory care pharmacists improve chronic disease outcomes and medication optimization; however, lack of sustainable reimbursement models remains a barrier to widespread implementation, particularly in hospital-based outpatient department (HOPD) primary care settings where traditional incident-to billing is unavailable. Emerging billing pathways, including chronic care management (CCM), and Medicare Annual Wellness Visits (AWVs), may improve financial sustainability.

OBJECTIVE

Characterize pharmacist billing activities across payer types in a traditional university-based HOPD primary care setting and estimate the associated annual reimbursement potential.

PRACTICE DESCRIPTION: Embedded clinical pharmacists practicing under collaborative drug therapy management agreements across nine University of Colorado HOPD primary care clinics (family medicine, internal medicine, geriatrics, and women's health) provided comprehensive medication management and chronic disease services. Pharmacists utilized Medicaid E/M billing, CCM services, and Medicare AWVs as available reimbursement pathways.

PRACTICE INNOVATION: A standardized billing model was developed to estimate reimbursement generated through pharmacist-provided clinical services using existing CPT codes across multiple payer types within HOPD primary care practices.

EVALUATION

METHODS

A mixed-methods cross-sectional evaluation was conducted. Pharmacists completed a survey describing estimated time allocation among billable clinical services, nonbillable patient care, and administrative activities. Billing data from October 2025 were analyzed to determine CPT code utilization per clinic day. Estimated reimbursement was calculated for Medicare, Medicaid, and commercial payers and annualized based on observed billing activity.

RESULTS

Pharmacists (6.95 full-time equivalents) reported a median of 45% of clinic work time devoted to billable clinical activities, 39% to nonbillable patient care, and 16% to administrative responsibilities. Estimated reimbursement averaged approximately $800 per pharmacist work week, corresponding to an annual reimbursement potential of $36,000 per pharmacist. CCM services generated 45% of estimated revenue and accounted for 55% of billable time, while AWVs contributed 31% of revenue and 28% of billable time, and Medicaid E/M services accounted for 24% of revenue while representing 17% of billable time.

CONCLUSION

Pharmacist billing in HOPD primary care settings is feasible but constrained by payer-specific reimbursement requirements. Complete financial sustainability through revenue generation alone is unlikely without changes in the pharmacist practice model directed at higher levels of billable activity.