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CCPP Certification Program
Module 15: Billing, Coding, and Reimbursement
From Clinical Value to Financial Viability: Securing Your Practice’s Future.
Translating Clinical Excellence into a Sustainable Practice
You have spent your entire career on the receiving end of the complex and often frustrating world of medical billing. You understand claim rejections, prior authorizations, and the financial barriers that prevent patients from accessing the medications they need. You have become an expert in navigating the consequences of a system you had no part in creating.
This module marks a fundamental shift in that dynamic. We will now move you from the receiving end to the driver’s seat. As a Collaborative Practice Pharmacist, you are no longer just a cost center in the healthcare system; you are a revenue-generating clinical provider. Your expertise, your time, and your positive patient outcomes are valuable, billable services. However, demonstrating this clinical value is not enough. To build a sustainable, scalable, and successful practice, you must learn to speak the language of reimbursement.
This module is your Rosetta Stone for the business of healthcare. We will deconstruct the opaque world of billing codes, reimbursement pathways, and payer contracts. You will learn not just what to do in the clinic, but how to get paid for it. Mastering this material is the final, critical step in your transformation. It is the skill that ensures your clinical practice is not just effective, but financially viable, allowing you to secure your role and expand the reach of pharmacist-led care for years to come.
Your Guide to the Reimbursement Landscape
This module will equip you with the essential financial and administrative skills to build and sustain your clinical practice.
15.1 Pharmacist Billing Pathways (Incident-To, Direct, Shared Visits)
A deep dive into the foundational mechanisms for pharmacist reimbursement. We will explore the nuances, requirements, and strategic advantages of billing “incident-to” a physician, direct billing models, and the criteria for shared evaluation and management (E/M) visits.
15.2 CPT and HCPCS Codes for Clinical Services
Learn to speak the language of medical billing. This section provides a practical masterclass on the most common CPT and HCPCS codes used by clinical pharmacists, from E/M codes for office visits to specific codes for chronic care management and transitional care.
15.3 Documentation for Audit-Ready Billing
Connect your clinical documentation directly to reimbursement. Learn how to structure your SOAP notes to support specific billing codes, satisfy the stringent requirements of payers like Medicare, and create an “audit-proof” record of your billable services.
15.4 Working with Payers and Credentialing Panels
A practical guide to becoming a recognized provider. We will walk through the process of provider credentialing, enrolling with commercial and federal payers, and strategies for navigating payer policies to ensure your services are covered and reimbursed.
15.5 Tracking Financial Metrics and Productivity Reports
Demonstrate your value with data. This section covers the key financial and productivity metrics used to measure the success of a CCPP service, from calculating RVUs (Relative Value Units) to creating reports that showcase your return on investment (ROI) to health system leadership.
