Medication Therapy Management Services
CPT Billing Codes
The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel has approved three CPT billing codes for pharmacists to use to bill third-party payors when providing medication Therapy Management Services (MTMS) were released July 1, 2005 and became effective January 1, 2006. The codes may be used to bill any health plan that provides a benefit for MTMS, including those covered under the new Medicare Part D.
Prescription Drug Benefit. Third-party payors will individually determine the reimbursement rates and criteria for MTMS.
For more information, please visit the AMA’s CPT info and education page. See also the press release, “Professional Service Billing Codes Approved for Pharmacists” under the “About Us” tab on this website.
The billing codes are intended to be used to bill third-party payors only for MTMS performed face-to-face between a pharmacist and a patient: Code 99605: the billing code for a first-encounter service performed face-to-face with a patient in a time increment of up to 15 minutes Code 99606: the code for use with the same patient in a time increment of up to 15 minutes for a subsequent or follow-up encounter Code 99607: an add-on code which may be used to bill for additional increments of 15 minutes of time to either of the preceding codes MTM services may be initiated at the request of the patient and/or caregiver, payer, pharmacist and/or other healthcare provider. The MTMS codes are not to be used to describe the provision of product-specific information (e.g., patient medication leaflets) at the point of dispensing. Similar to the documentation requirements for other health care providers the following elements are required to verify the service provided and are dependent on the type and level of MTMS: review of the pertinent patient medical history; medication profile (prescription and non-prescription); interventions and recommendations for optimizing medication therapy; referrals, treatment compliance; communications with other healthcare professionals; administrative functions (including patient and family communications) relative to the patient care; and/or follow-up care.
For more information, please visit the AMA’s CPT info and education page
Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0
Eleven national pharmacy organizations achieved consensus on a definition of medication therapy management (MTM) in July 2004. Building on the consensus definition, the American Pharmacists Association and the National Association of Chain Drug Stores Foundation developed a model framework for implementing effective MTM services in a community pharmacy setting by publishing Medication Therapy Management in Community Pharmacy Practice: Core Elements of an MTM Service Version 1.0. The original version 1.0 document described the foundational or core elements of MTM services that could be provided by pharmacists across the spectrum of community pharmacy.
Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0 is an evolutionary document that focuses on the provision of MTM services in settings where patients* or their caregivers can be actively involved in managing their medications. This service model was developed with the input of an advisory panel of pharmacy leaders representing diverse pharmacy practice settings. While adoption of this model is voluntary, it is important to note that this model is crafted to maximize both effectiveness and efficiency of MTM service delivery across pharmacy practice settings in an effort to improve continuity of care and patient outcomes.
* In this document, the term patient refers to the patient, the caregiver, or other persons involved in the care of the patient.
To view Version 2.0, please visit the NACDS Foundation website at http://www.nacdsfoundation.org or APhA’s website at http://www.pharmacist.com/mtm/CoreElements2.
Medication Therapy Management Services Definition and Program Criteria
Medication Therapy Management is a distinct service or group of services that optimize therapeutic outcomes for individual patients. Medication Therapy Management Services are independent of, but can occur in conjunction with, the provision of a medication product. Medication Therapy Management encompasses a broad range of professional activities and responsibilities within the licensed pharmacist’s, or other qualified health care provider’s, scope of practice. These services include but are not limited to the following, according to the individual needs of the patient:
- Performing or obtaining necessary assessments of the patient’s health status;
- Formulating a medication treatment plan;
- Selecting, initiating, modifying, or administering medication therapy;
- Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness;
- Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events;
- Documenting the care delivered and communicating essential information to the patient’s other primary care providers;
- Providing verbal education and training designed to enhance patient understanding and appropriate use of his/her medications;
- Providing information, support services and resources designed to enhance patient adherence with his/her therapeutic regimens;
- Coordinating and integrating medication therapy management services within the broader health care-management services being provided to the patient.
A program that provides coverage for Medication Therapy Management Services shall include:
- Patient-specific and individualized services or sets of services provided directly by a pharmacist to the patient*. These services are distinct from formulary development and use, generalized patient education and information activities, and other population-focused quality assurance measures for medication use.
- Face-to-face interaction between the patient* and the pharmacist as the preferred method of delivery. When patient-specific barriers to face-to-face communication exist, patients shall have equal access to appropriate alternative delivery methods. Medication Therapy Management programs shall include structures supporting the establishment and maintenance of the patient*-pharmacist relationship.
- Opportunities for pharmacists and other qualified health care providers to identify patients who should receive medication therapy management services.
- Payment for Medication Therapy Management Services consistent with contemporary provider payment rates that are based on the time, clinical intensity, and resources required to provide services (e.g., Medicare Part A and/or Part B for CPT & RBRVS).
- Processes to improve continuity of care, outcomes, and outcome measures.
* In some situations, Medication Therapy Management Services may be provided to the caregiver or other persons involved in the care of the patient.
Approved July 27, 2004 by the Academy of Managed Care Pharmacy, the American Association of Colleges of Pharmacy, the American College of Apothecaries, the American College of Clinical Pharmacy, the American Society of Consultant Pharmacists, the American Pharmacists Association, the American Society of Health-System Pharmacists, the National Association of Boards of Pharmacy**, the National Association of Chain Drug Stores, the National Community Pharmacists Association and the National Council of State Pharmacy Association Executives.
** Organization policy does not allow NABP to take a position on payment issues.
Click here for the Definition and Program Criteria in pdf format