Module 7: Billing, Coding & Reimbursement

You have mastered the intricacies of clinical management, navigated the complex labyrinth of patient access, and become an expert financial shield for your patients. Now, we shift focus to the operational backbone that makes specialty pharmacy possible: the intricate world of billing, coding, and reimbursement.

As a community pharmacist, you were largely insulated from this. Claims were submitted, adjudicated in seconds, and payment (however meager) arrived weeks later. In specialty, particularly within hospitals, health systems, or independent practices, the pharmacist is deeply embedded in the revenue cycle. Understanding how claims are coded, submitted, denied, appealed, and ultimately paid is not just an administrative task—it is fundamental to the financial viability of your service and your ability to care for patients.

This module translates your existing knowledge of NDCs and basic billing into the complex language of medical coding (HCPCS, CPT), revenue codes, complex billing models like “buy-and-bill,” and the strategies needed to fight for every dollar of reimbursement. You will learn to think like a revenue cycle manager, identifying potential denial pitfalls before they happen, crafting powerful appeals, and understanding the opaque world of DIR fees and payer reconciliation. This is the business side of saving lives, and mastering it is essential for the advanced specialty practitioner.