The pharmacist and MTM services

A variety of services

Some examples of MTM include:

Historically, pharmacist reimbursement has been linked to the distribution of a drug product. Although some visionary pharmacists sought ways to receive reimbursement separate and distinct from the drug product, payment for cognitive services in this connection was not fully realized. However, under the MTM concept, pharmacists are now being paid for these services by federal healthcare payers such as Medicare, as well as by nongovernmental third-party payers.

HIPAA and CPT

MTM reimbursement efforts gained traction when the Health Insurance Portability and Accountability Act provided that all claims submissions follow specified electronic data interchange requirements. This mobilized pharmacy associations to unite and propose a formal Current Procedural Terminology (CPT) code for MTM services. Discussions ensued and MTM was assigned to so-called Category III, which denotes temporary status used in reporting emerging services. These MTM CPT codes were published in CPT 2006 and 2007.

While in Category III, the MTM CPT codes established a "pharmacy" as a place-of-service, and pharmacists were given the ability to obtain a National Provider Identifier number. Soon thereafter, the Pharmacist Services Technical Advisory Coalition (PSTAC) undertook broadband efforts to demonstrate to the CPT editorial panel that MTM had widespread availability.

This was done through conduct of national surveys designed to qualify the extent of MTM services rendered by pharmacists. The survey results showed pharmacist encounters in the millions and present in every state, the District of Columbia, and Puerto Rico.

The data were presented to the CPT editorial board members, and they, in turn, summarily changed MTM from Category III to Category I. Category I codes are assigned to those procedures or services that reflect contemporary practice performed routinely by practitioners in a multitude of locations.

Although federal regulations impacting programs such as Medicare helped facilitate the MTM reimbursement movement, CPT codes for MTM services may be used in all practice settings and for all types of payers that go beyond Medicare. Nevertheless, it should be pointed out that each plan design dictates its own scope of reimbursement for MTM services and the way CPT codes should be applied.

Proof of value

Pharmacists seeking to implement MTM services in accordance with CPT codes may obtain additional information from PSTAC and the national pharmacy associations that have invested in the MTM reimbursement movement. Key to continued expansion of payer reimbursement for MTM services will be establishing the value of such services.

Pharmacies that embrace MTM reimbursement by properly realigning operations to facilitate pharmacist MTM services into workflow can benefit both patients and payers.

This article is not intended as legal advice and should not be used as such. When legal questions arise, pharmacists should consult with attorneys familiar with the relevant drug and pharmacy laws.

Ned Milenkovich is a member at McDonald Hopkins, LLC, and chairs its drug and pharmacy practice group. He is also a member of the Illinois State Board of Pharmacy. Contact Ned at 312-642-1480 or at nmilenkovich@mcdonaldhopkins.com
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