Journal of the American Pharmacists Association : JAPhA · 2026
Integration of a complexity billing tool to evaluate unrealized pharmacist revenue and productivity in an academic primary care network.
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Marshall Kara P, Leupold Sarah, Grandominico Jodi M, Tayal Neeraj H, Coffey Cory P
Аннотация
BACKGROUND: Pharmacists are not recognized as health care providers under the Social Security Act. This limitation often confines pharmacists to "incident-to" billing for clinical services, which is commonly used for the simplest level of care, equating to the lowest reimbursement from payers.
OBJECTIVE: Primary objectives of this study were to (1) compare the actual and potential unrealized revenue for pharmacist-provided services using a complexity billing tool adjusted for the level of care provided and (2) compare the actual and simulated work relative value unit (wRVU) for pharmacist-provided services. The secondary objective was to measure the proportion of pharmacist-provided services billed at lower Evaluation and Management codes due to payer restrictions compared to the simulated complexity code.
PRACTICE DESCRIPTION: Serving over 70,000 patients, the clinic network operates within an interdisciplinary team of ∼100 residents and 80 attending physicians, supported by a pharmacy group of 12 pharmacists (7.7 clinical full-time equivalents) and 3 residents.
PRACTICE INNOVATION AND EVALUATION: To more accurately capture the level of service provided during scheduled pharmacy visits, a complexity billing tool aligned with the 2021 American Medical Association Medical Decision-Making Criteria was applied to each pharmacist encounter. This tool served as a proxy to accurately demonstrate the level of care delivered by the pharmacists, regardless of payer restrictions. All encounters with a pharmacist listed as the service provider from July 1, 2024, to June 30, 2025, were identified using Qlik, a secure, analytics-integrated platform. Remote physiologic monitoring encounters were excluded.
RESULTS: Implementation of the complexity billing tool revealed that approximately 50% of visits were classified as underbilled due to billing restrictions. On average, reimbursement based on the actual level of service was 39% lower and the mean wRVU was approximately 0.45 points lower when calculated using the actual level of service billed.
CONCLUSION: Implementation of a complexity billing tool in a primary care setting provided an effective method for capturing the actual complexity of pharmacist visits through calculation of simulated revenue and wRVUs.
OBJECTIVE: Primary objectives of this study were to (1) compare the actual and potential unrealized revenue for pharmacist-provided services using a complexity billing tool adjusted for the level of care provided and (2) compare the actual and simulated work relative value unit (wRVU) for pharmacist-provided services. The secondary objective was to measure the proportion of pharmacist-provided services billed at lower Evaluation and Management codes due to payer restrictions compared to the simulated complexity code.
PRACTICE DESCRIPTION: Serving over 70,000 patients, the clinic network operates within an interdisciplinary team of ∼100 residents and 80 attending physicians, supported by a pharmacy group of 12 pharmacists (7.7 clinical full-time equivalents) and 3 residents.
PRACTICE INNOVATION AND EVALUATION: To more accurately capture the level of service provided during scheduled pharmacy visits, a complexity billing tool aligned with the 2021 American Medical Association Medical Decision-Making Criteria was applied to each pharmacist encounter. This tool served as a proxy to accurately demonstrate the level of care delivered by the pharmacists, regardless of payer restrictions. All encounters with a pharmacist listed as the service provider from July 1, 2024, to June 30, 2025, were identified using Qlik, a secure, analytics-integrated platform. Remote physiologic monitoring encounters were excluded.
RESULTS: Implementation of the complexity billing tool revealed that approximately 50% of visits were classified as underbilled due to billing restrictions. On average, reimbursement based on the actual level of service was 39% lower and the mean wRVU was approximately 0.45 points lower when calculated using the actual level of service billed.
CONCLUSION: Implementation of a complexity billing tool in a primary care setting provided an effective method for capturing the actual complexity of pharmacist visits through calculation of simulated revenue and wRVUs.