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

March 5, 2007

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 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 CPT Manual 2008, 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.