Obtaining reimbursement for clinical pharmacokinetic monitoring

A method of obtaining reimbursement for clinical pharmacokinetic monitoring is described. The process included reviewing the existing literature, observing the practices of others providing similar services, collecting workload and expense data, selecting an equitable fee, and presenting third party payers with evidence of the service's need, documentation, and effectiveness. The average patient was monitored by the pharmacokinetic service for 8.4 days and had 5.1 serum samples drawn. The physician received 3.1 dosing recommendations. An average of 4.3 hours was spent monitoring each patient with an average cost of $86. Of the several alternatives for charging considered, an inclusive charge of $10 per patient day was chosen. Blue Cross reimbursement criteria for pharmacokinetic monitoring stipulated that (1) the service must be physician initiated; (2) documentation of services provided must appear as a permanent part of the patient's record; (3) service provided must be identified with a specific group of patients rather than applied equally to all patients in the institution; and (4) evidence of reduced morbidity, mortality, or length of hospital stay would help. During 1981, $37,470 in charges was generated for pharmacokinetic monitoring services with reimbursement being received from third party programs, insurance companies, and private patients.