Integration of a complexity billing tool to evaluate unrealized pharmacist revenue and productivity in an academic...

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.

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.

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.

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.

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.

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.