Pharmacist-Led Care Terms
Pharmacist-Led CareClinical care delivered or supported by a pharmacist, including medication optimization, chronic disease management, education, monitoring, and care coordination.
Ambulatory CareOutpatient care provided outside the hospital, such as in clinics, physician offices, pharmacies, telehealth, or community settings.
Primary CareOngoing general healthcare focused on prevention, chronic disease management, medication safety, and care coordination.
Clinical Consulting PharmacistA pharmacist who provides clinical, operational, or consulting services to physicians, clinics, pharmacies, employers, or patients.
CMMComprehensive Medication Management: a full medication review focused on safety, effectiveness, adherence, interactions, and optimization.
MTMMedication Therapy Management: a structured pharmacy service used to review medications and address medication-related problems.
Legal, Regulatory & Compliance Terms
CPACollaborative Practice Agreement: a formal agreement between a pharmacist and prescriber defining allowed clinical services under state law.
Scope of PracticeThe legal boundaries of what a healthcare professional may do under their license and state regulations.
BOPBoard of Pharmacy: the state agency that regulates pharmacy practice and pharmacist licensure.
CPOMCorporate Practice of Medicine: state rules that may restrict who can own, control, or profit from clinical medical decision-making.
MSOManagement Services Organization: a business entity that manages non-clinical operations such as administration, IT, billing support, staffing, or marketing.
HIPAAHealth Insurance Portability and Accountability Act: federal law protecting patient health information.
PHIProtected Health Information: individually identifiable patient health information.
BAABusiness Associate Agreement: a required HIPAA agreement with vendors or partners who may access PHI.
CMSCenters for Medicare & Medicaid Services: the federal agency that oversees Medicare, Medicaid, billing rules, and healthcare payment programs.
OIGOffice of Inspector General: federal agency focused on fraud, waste, abuse, and healthcare compliance oversight.
AKSAnti-Kickback Statute: federal law prohibiting improper payments or incentives for referrals or healthcare business.
FMVFair Market Value: compensation that is reasonable, market-based, and not tied to referrals or patient volume.
Billing & Reimbursement Acronyms
CPTCurrent Procedural Terminology: medical billing codes used to describe healthcare services.
HCPCSHealthcare Common Procedure Coding System: billing codes used for Medicare and other payers, including services, supplies, and preventive codes.
ICD-10Diagnosis coding system used to support medical necessity for services.
E/MEvaluation and Management: office or outpatient visit codes used for clinical encounters.
Incident-ToA billing model where services performed by clinical staff, such as pharmacists, may be billed under a supervising provider when requirements are met.
PFS / MPFSPhysician Fee Schedule / Medicare Physician Fee Schedule: Medicare’s payment schedule for professional services.
RVURelative Value Unit: a value used by Medicare to calculate payment for services.
POSPlace of Service: a billing code that identifies where a service was provided.
Modifier 25A billing modifier showing that a significant, separately identifiable E/M service occurred on the same day as another service or procedure.
Medical NecessityThe clinical reason a service is appropriate, reasonable, and needed for diagnosis or treatment.
SuperbillA document or workflow that organizes services provided and the billing codes connected to them.
Code StackingCombining compatible billing codes when separate services are performed and properly documented.
Common Clinical Billing Programs
CCMChronic Care Management: monthly care coordination for patients with two or more chronic conditions.
PCMPrincipal Care Management: care management for one serious chronic condition requiring ongoing management.
RPMRemote Physiologic Monitoring: remote monitoring of physiologic data such as blood pressure, glucose, weight, or oxygen saturation.
RTMRemote Therapeutic Monitoring: remote monitoring of therapy response, medication adherence, respiratory status, or musculoskeletal therapy data.
TCMTransitional Care Management: care provided after discharge from a hospital or skilled nursing facility.
AWVAnnual Wellness Visit: a Medicare preventive visit focused on risk assessment, screenings, and a personalized prevention plan.
IPPEInitial Preventive Physical Exam: the “Welcome to Medicare” visit available once within the first 12 months of Medicare Part B enrollment.
ACPAdvance Care Planning: a documented conversation about future healthcare decisions, advance directives, or goals of care.
BHIBehavioral Health Integration: care management services supporting behavioral health screening, coordination, and follow-up.
DSMEDiabetes Self-Management Education: structured diabetes education to help patients manage diabetes safely and effectively.
CGMContinuous Glucose Monitoring: a device or system that tracks glucose trends throughout the day.
CLIAClinical Laboratory Improvement Amendments: federal rules for laboratory testing; some practices need a CLIA waiver for point-of-care testing.
