Pharmacy reimbursement: Make the most of MTM


Even without provider status, there's more to delivery of MTM services than some pharmacists may think. Here's a breakdown.

Pharmacists are missing many opportunities to bill for medication therapy management (MTM). During a recent webinar sponsored by Wolters Kluwer Clinical Drug Information, Brian Isetts, RPh, PhD, offered suggestions to turn that around.

According to Isetts, pharmacists involved in MTM are not valuing their services, which include not only medication reviews with patients, but also pre-service work, such as gathering patient records and labs, as well as post-service functions that include consulting and communicating with patients. In addition, there are practice expenses connected with delivery of MTM, such as equipment, rent, and professional liability insurance.

“At some point in the future, our service will actually be valued. Value is based on the time and intensity of work required for the service,” Isetts said.


Incomplete billings

In many cases, pharmacists are not completely billing for all their time and for every service involved in helping patients manage their medications.

For example, when Minnesota Medicaid audited MTM claims, the agency found that 30% of those claims were underbilled and only 9% were overbilled, Isetts said. Minnesota Medicaid provides reimbursement for pharmacists’ medication review services using Current Procedural Terminology (CPT) codes set by a resource-based relative value scale (a tiered payment system), ranging from $34 to $148 per encounter, according to Isetts.

Some of the MTM billing codes that pharmacists can use include those listed under "Incident-to-physician office visit," "Incident-to-physician transitional care management," "Annual wellness visit," and "Immunization administration." 


In the works

Changes underway at the Centers for Medicare and Medicaid Services (CMS) may also help pharmacists obtain better reimbursements for MTM services in the future, according to Isetts.

“[CMS] recognizes that we have to get to benefit alignment between Medicare Part D and Medicare Parts A and B. Medicare ACOs will soon be held accountable for drug costs in their total cost of shared savings,” Isetts said.

Public comments on CMS’s Request for Information on Medicare benefit alignment must be received by November 3, 2014.

Another untapped resource is Section 3503 of the ACA, which is not yet funded. This will provide a “clear service-level description of the comprehensive assessment of all of a drug beneficiary’s drug-related needs,” Isetts said. “It would help health systems, organizations, and communities build the infrastructure needed for comprehensive, team-based medication management.”

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