Catherine MacRae Hockmuth

MTM refers to in-person services for patients beyond routine dispensing of prescription medication and related information leaflets. The codes are used to bill any health plan that covers MTM services, including the Medicare Part D prescription drug benefit.  

The MTM CPT codes were created in 2005 and became effective in January 2006 in category III. Category III codes are temporary codes created for emerging technology either to collect data for FDA approval or to confirm widespread usage. Over the past two years, there have been nearly 900,000 documented cases of MTM services at 240 pharmacy sites across the United States, reported Daniel Buffington, Pharm.D., MBA. Buffington sits on the CPT editorial panel as a representative of the Pharmacist Services Technical Advisory Coalition (PSTAC). He is also president and CEO of Clinical Pharmacology Services. He presented the findings of a recent survey of pharmacists and third-party payers regarding MTM services. 

PSTAC used the example of a 66-year-old female with osteoporosis, Type 2 diabetes, and hyperlipidemia.  

Assessment of a patient with multiple diseases and Rxs may include taking a full medical and medication history; determining the appropriateness of the prescribed therapy; assessing lab data; assessing the potential for negative interactions involving multiple Rx drugs, drugs and the disease, and drugs and other nutrients; and developing a plan to optimize therapy.  

The pharmacist reviews all medications, including Rxs, over-the-counter drugs, and herbal supplements being used by the patient for negative interactions, duplications, and under- or overdosing.   

The editorial panel's Feb. 8 vote on the proposal is confidential until AMA publishes its 

 expected in August. If the proposal is approved by the panel, the codes will be effective in January 2008 as category I codes, according to Kathryn Kuhn, R.Ph., executive secretary of PSTAC, who was also present at the meeting. Category I comprises permanent codes created for medical procedures or services that are routinely performed by physicians or healthcare providers across the country. 

PSTAC surveyed pharmacists regarding MTM services over three months from August through October 2006. The survey asked about their practice, how long they've been providing MTM services, how many MTM interventions had been documented in the past two years, how patients were referred for MTM services, and whether they used the MTM CPT codes to bill healthcare plans. The survey showed that MTM services are provided by pharmacies in all 50 states, the District of Columbia, and Puerto Rico. The number of interventions reported totaled 858,405, and 86% occurred at ambulatory care practice sites such as community pharmacies, clinic and physician offices, outpatient pharmacies, work sites, and home and hospice care. 

On average, respondents said they have been providing MTM services for six years; however, at least one respondent had been providing such services for more than 30 years. Physicians and healthcare professionals are the source of most MTM referrals, although some patients referred themselves. More than 25% of the respondents said they submit MTM claims using the CPT codes released in 2006.  

In a separate survey of Veterans Affairs pharmacies, PSTAC found evidence of more than 1.8 million face-to-face MTM interventions in 2005 and 2006.  

PSTAC also questioned third-party payers to determine whether they're approving MTM claims under the temporary codes. In a three-month survey conducted from July to September 2006, PSTAC found three payers compensating claims that used the CPT codes, while others still used a proprietary system, the X12N 837, CMS (Centers for Medicare & Medicaid Services) 1500 format, or some other system. Payers reported that 88% of MTM claims involved comprehensive medication reviews and resolution of drug therapy problems. 

Catherine MacRae Hockmuth is a freelance writer based in San Diego. 

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Pharmacy representatives attending an American Medical Association's Current Procedural Terminology (CPT) editorial panel meeting recently in San Diego have asked the panel to make codes for medication therapy management (MTM) permanent.

MTM codes may become permanent, R.Ph.s hope

Bell said there has been an uptick in fraud and abuse investigations by the Bush Administration, with several agencies seeing "exponential growth" in spending on audits and compliance efforts-particularly for the pharmaceutical industry. The increased budgets have been used to hire more auditors and lawyers, including 140 new assistant U.S. attorneys trained specifically on healthcare fraud, and more funding for the Department of Health & Human Services' Office of Inspector General. The Centers for Medicare & Medicaid Services is already planning to hire 100 new employees to prevent fraud and abuse as part of its Medicaid Integrity Program announced in July.  

Bell said that in addition to providing extensive employee training on fraud and abuse, pharmacies should check new hires against federal and state lists of individuals prohibited from participating in Medicare or Medicaid programs and develop comprehensive employee and conflict-of-interest policies.  

				"It's really all about the money," said Bell, noting that his presentation could be titled, "How you can get in trouble, lose your job, and wind up in jail."			

Bell noted that although CMS has issued two sets of extensive guidelines on fraud and abuse over the past year, it's not always easy to tell the differ-ence between requirements and recommendations. "Everyone should expect increased audits at the federal, state, and government contractor level," said Bell. "And they're going to be using some techniques that we don't particularly like."  

For example, he said, CMS plans to use the Medicare-Medicaid Data Match Pilot Program (Medi-Medi data mining program) designed to look for patterns of billing for Medicare and Medicaid. CMS will also be conducting "extrapolation audits" in which it examines a subset of claims and applies the findings to the larger data set. If, for example, auditors believe false claims represent 1% or 2% of the subset, they will assume a similar percentage of false claims across the entire data set.  

Agencies may also hire private "bounty hunter" auditors who will be paid based on how much fraud they uncover.  

"This really goes beyond an audit," said Bell. "This is actually more of an accreditation process." 

Auditors will be particularly focused on violations of the federal False Claims Act, which include presenting the government with false Medicare or Medicaid claims for payment, causing someone else to present a false claim, conspiring to get a false claim paid, making or using a false record or statement to get a claim paid, and making or using a false record to avoid or decrease an obligation to pay or reimburse the federal government.  

Penalties for violating the false claims law include fines of $5,000 to $10,000 for each false claim, plus treble damages suffered by the government, trial costs, exclusion from Medicare and Medicaid, and even criminal prosecution.  

Understanding the nuances of anti-kickback laws will be particularly tricky for pharmacies, because the laws include complicated exceptions. For example, drug-switching programs in which drugmakers pay pharmacists who get patients to switch drugs can be legal if structured properly. But the drugmakers can't just make payments based on the volume or dollar value of drugs sold as a result. What pharmacies can do is enter "professional services contracts" with drugmakers in which manufacturers pay pharmacists for the value of their time spent talking to patients about a specific drug.  

Pharmacies across the country must better train employees and develop clear polices to avoid being investigated or prosecuted for fraud and abuse related to Medicare and Medicaid, said Don L. Bell II, general counsel of the National Association of Chain Drug Stores, at an NACDS Pharmacy & Technology Conference held recently in San Diego.

Pharmacies prepare for fraud and abuse audits

"There's a notion that mail order saves money," Johnsrud said at the recent National Association of Chain Drug Stores Pharmacy & Technology Conference in San Diego. "We found that there really isn't a whole lot of published evidence." 

After a comprehensive review of existing literature on mail-order pharmacies, Johnsrud concluded that there is not a single, well-controlled, objective, peer-reviewed article that measured net costs to plans of mail order compared with community pharmacies.  

Most of the existing literature on mail-order pharmacies is highly anecdotal and produced by nonobjective sources such as think tanks and marketing materials, said Johnsrud. As a result, employers and other plan sponsors widely believe mail order saves them money due to economies of scale, lower overhead, greater efficiency, and more aggressive efforts to encourage the use of generics.  

Plan sponsors should more fully analyze the net costs of mail-order services, a task that is impeded by lack of transparency in the mail-order industry, Johnsrud said. Plan sponsors should also be aware that mail-order pharmacies often have conflicts of interest. For example, Johnsrud's study found that 66% of mail-order Rxs in the third quarter of 2003 were filled by four PBMs, which have been investing heavily in their own mail-order pharmacies. 

Johnsrud said transparency is increasing among PBMs but that more data are needed about their revenues and profit margins. More employers are starting to demand this transparency from PBMs. The Human Resources Policy Association, a coalition of more than 250 of the largest U.S. corporations, developed a transparency agreement under the title "Transparency in Pharmaceutical Purchasing Solutions," or TIPPS.  

The agreement requires pharmacies to disclose the actual acquisition costs of drugs and to pass through all rebate revenue, increase competition among PBMs based on administrative services and clinical management, and provide incentives for employees to maximize cost-effective therapies.  

In July the association announced it has certified 10 PBMs under the TIPPS agreement: Aetna Pharmacy Management, Caremark, CIGNA, Medco, Restat, Blue Cross/Blue Shield of Alabama, Catalyst Rx, HealthTrans, MedImpact, and Walgreens Health Initiatives. "It doesn't mean they're developing transparent models with all their clients, just the clients in this group," said Johnsrud.  

After conducting his own study of two publicly funded programs in Texas, Johnsrud found that although net cost to enrollees is often lower through mail order, plan sponsors pay more than they would if the drugs were purchased through a community pharmacy.  

Determining actual cost savings requires a much more sophisticated look at the claims data that administrators in charge of selecting programs for plan sponsors often lack the experience or background to conduct, according to Johnsrud. Factors other than unit pricing that should be considered include the effects of discounts and rebates, costs per enrollee month or cost per day rather than cost per claim, and the impact of product waste.  

The study found that in "Plan A," eight of the top 20 generic mail-order drugs had a higher per-unit cost when purchased by mail rather than retail. A similar variability in per-unit costs between retail and mail-order drugs existed in "Plan B."  

Mail-order pharmacies may not always provide the lowest costs for employers, despite conventional wisdom to the contrary, according to Michael Johnsrud, associate director of the Center for Pharmacoeconomic Studies at the University of Texas at Austin College of Pharmacy.

Author | Catherine MacRae Hockmuth

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