Pharmacy Billing for Clinical Services: Part 2

Community pharmacists’ hard work to provide more accessible healthcare is increasingly being recognized by payers. This can provide new revenue to offset decreased prescription reimbursements.

But what do pharmacists need to know to start taking advantage of medical billing?

In Part 1, we talked about differences in billing for prescriptions versus clinical services. This post digs deeper into some workflow specifics to outline the steps of successfully billing for medical services.

How to Get Reimbursed for Clinical Services

Learn. Understand federal, state, and payer requirements to perform and be reimbursed for clinical services. What’s allowed and reimbursed varies by where you practice pharmacy and by the payers involved. Stay up to date with what’s happening in your state by subscribing to the NextWave Pharmacy Newsletter or the RedSail Blog.

Verify. Have a real-time eligibility check with the selected payer to ensure compliance with medical benefit coverage and reduce the risk of denials and audits. Finding out that a certain patient or service wasn’t covered after the fact is nothing but problematic.

Document. Create guided documentation that’s integrated into the existing pharmacy workflow that follow regulatory and reimbursement requirements. The goal is to record the information needed for insurance claims and legal considerations as part of the service encounter.

Bill. Use integrated claims processing with denial management to ensure optimal reimbursement. These systems can often catch and correct the small errors that prevent the claim from being paid.

Share. Communicate patient results electronically with other healthcare providers, state registries, and public health organizations. Doctors should know about the disease education, point-of-care testing, or medication management you’re providing for their patient. You should also report immunizations to the state, certain test results to health agencies, etc.

As discussed in Part 1, credentialing and contracting is crucial to pharmacists being able to bill for services under medical coverage is. This requires pharmacists to:

  • Declare yourself: Enroll properly with Medicare and complete initial forms with other payers.
  • Describe yourself: Update NPI taxonomy codes for your organization and yourself and get the CAQH profile started.
  • Get connected: Connect with a medical claims processor to submit claims and ensure enhanced eligibility.

Clinical Services Reimbursed by Payers

Considering the steps outlined above, there’s no getting around the fact that medical billing requires a time investment, and that can be a barrier to already harried community pharmacists.

There are programs that have stepped in to fill that need, including RedSail Medical Billing.

Assuming you’ve taken the needed steps to prepare for medical billing, let’s consider what clinical services are commonly being reimbursed by payers. Depending on location, pharmacists’ options could include:

  • Hormonal contraceptive therapy
  • Education (tobacco cessation, diabetes education, pre-diabetes education)
  • Medication Therapy Management (MTM)
  • Office visits
  • Point-of-care testing including flu, strep, and Covid

Before moving into a big area not included in the list above (immunizations), let’s look at a few others.

  • Diabetes Self-Management Education (DSME): This requires a specific diabetes accreditation for your group, but it does not require you to be a Certified Diabetes Educator. Medicare pays for up to 10 hours initially, then two hours follow-up each year. You’ll need to declare yourself by enrolling as a pharmacy.

  • Diabetes Prevention Program (DPP): One out of every three U.S. adults is living with pre-diabetes. Medicare pays for DPP, but it requires a different accreditation from DSME. Accreditation is virtually free, but you must submit data before you’re approved. Services are submitted as a medical claim, and payment is based on how much weight the patient has lost.

  • Hormonal Contraception Therapy Writing: Over a dozen states allow pharmacists to bill for their time. This requires basic individualized credentialing for most insurances (e.g., Oregon). Services are submitted as a medical claim; the birth control product is submitted as a pharmacy claim.


Now to vaccination. As of November 2023, over 150 million doses of the flu vaccine have been distributed – a number that is only expected to grow as the season progresses. But immunization “season” can more accurately be considered year-round, with flu August through February, Covid ever present, and Zoster and HPV relevant all year.

It may be possible to use your pharmacy management system to submit both pharmacy and medical immunizations claims: pharmacy claims with NDC codes and medical claims with CPT and ICD-10 codes. It’s important to remember to also bill the administration codes; codes are often unique to the specific immunization.

Another key consideration for implementing or expanding immunization services is defining your workflow, especially in light of the increased volume and duration of immunization season.


Paperless pharmacist documentation can streamline workflow and reduce documentation time significantly. A solution can populate previous vaccine history, have details auto-populate via the NCPDP® claim, and allow you to print as well as proceed completely digitally.

Documentation can be sent securely to the patient via text, eliminates the standard clipboard/pen process, and includes discreet data points that would exclude patients from receiving the vaccine if needed. It can also include technology to highlight companion vaccines.


Pharmacy billing for medical services brings benefits that make the effort worth it: practicing at the top of your license, being reimbursed for the holistic care you’re providing, and sharing valuable insights with the patient’s whole medical community.

Even better, solutions do exist to ease the process of becoming qualified and equipped to start billing.

Learn more about RedSail’s billing solutions here.

Written by:
Emily Smith
Product Marketing Manager, RedSail Technologies
Emily Smith

Emily loves to learn and connect ideas in new ways, with a focus on customers' needs and empathy for their challenges. In her role as RedSail product marketing manager, Emily educates on innovation and encourages its use to improve pharmacy care.

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