CPT code for MTM reflects new reimbursement arena

July 25, 2005

In the world of medical reimbursement, having a "CPT code" for a type of professional effort or procedure is much like having its existence recognized. Medication therapy management (MTM) services by pharmacists crossed that threshold on July 1, when the American Medical Association's official list of procedures added three codes for MTM?initial service, subsequent service, and additional time, each in 15-minute blocks?in its chapter on cognitive services.

In the world of medical reimbursement, having a "CPT code" for a type of professional effort or procedure is much like having its existence recognized. Medication therapy management (MTM) services by pharmacists crossed that threshold on July 1, when the American Medical Association's official list of procedures added three codes for MTM-initial service, subsequent service, and additional time, each in 15-minute blocks-in its chapter on cognitive services.

The Current Procedural Terminology (CPT) manual describes MTM, in part, "as a form of face-to-face assessment or intervention between a pharmacist and a patient or caregiver that is provided to optimize and improve the response to medications and to help avoid potential treatment-related medication interactions or complications. These intervention services may be accomplished in a variety of settings. Patients may access these services through practitioner, insurer, pharmacist, or self-directed referrals."

Daniel E. Buffington, Pharm.D., M.B.A., is pharmacy's representative to AMA's CPT committee and worked with that body for more than a year to get the code accepted. He wants pharmacists to understand the basic shift it represents and how they can prepare their practices for MTM and getting paid for it. Buffington represented the Pharmacist Services Technical Advisory Coalition (PSTAC), a group of eight pharmacist organizations formed in 2002 to improve the coding structure to support billing for pharmacists' professional services.

The codes are to be effective Jan. 1, 2006. Initially, third-party payers will individually determine reimbursement and criteria for MTM services, according to PSTAC. In addition, pharmacists also now have a Place of Service (POS) code to indicate "Pharmacy." Attaining the code, Buffington said, is one achievement of the impressive collaboration working to have the profession embrace traditional medical billing and evolve toward the reimbursement standards in the rest of health care. Buffington spoke last month at a meeting in Washington, D.C., on MTM implementation, sponsored by the American Pharmacists Association and the National Association of Chain Drug Stores Foundation.

It can all be confusing, Buffington noted, but the well-established CPT system has many published materials to explain it. He also emphasized that learning another coding system is for a very good cause. The mandate for MTM in the Medicare prescription benefit has solidified recognition of the services. But, he asserted, the shift goes far beyond Medicare.

Buffington, who heads Clinical Pharmacology Services in Tampa, Fla., said that in his area such entities as the University of South Florida, the school system, and other large employers have sought help from someone who "sounds like a pharmacist." Most telling, he thinks, is the high percentage of patients in his practice who pay for these services themselves, even though they come from varying economic levels.

The codes, Buffington noted, apply to every practice setting. He cautioned pharmacists to look at how their state practice acts relate to these issues. At the same time, he said, changes to practice acts over the past 10 years have often simply validated what pharmacists were already doing. Obviously, he said, pharmacists will continue to counsel on drugs they dispense. But these new clinical services are separate from product-related information. For example, he said, providing a patient with a leaflet when you are dispensing may be education, but in the payer's eyes it is an inherent part of the dispensing.

That doesn't mean, said Buffington, "you can't go beyond that at any point of care, in any setting, and provide more counseling and so on. The point is identifying what in your setting goes with the product and what doesn't."

The CPT definition notes that MTM is distinct from information at the point of dispensing, involving "a documented review of the patient, history, chief complaint or concern, medication profile (Rx and nonprescription), and any recommendations for improving health outcomes and the level of treatment compliance. These codes are to be used by pharmacists."