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Medication Therapy Management Services (MTMS)

Revised: 08-25-2015

  • Eligible Providers
  • Enrollment Applications and Agreements
  • MTMS Privacy and Space Requirements (Business Setting)
  • MTMS Patient Documentation
  • Eligible Recipients
  • Covered Services
  • MTMS Delivered via Interactive Video (ITV)
  • Noncovered Services
  • Billing
  • HIPAA-compliant MTMS CPT Codes
  • Billing Limitations
  • Billing Instructions
  • Additional Information and Resources
  • The 2005 Minnesota Legislature directed the Minnesota Department of Human Services (DHS) to pay qualified pharmacists for Medication Therapy Management Services (MTMS) for Medical Assistance (MA) or MinnesotaCare recipients effective for dates of service on or after April 1, 2006. The MTMS program was developed with input from an advisory committee representing pharmacy groups and other interested parties.

    Eligible Providers

    To provide MTMS, pharmacists must enroll individually with MHCP and meet all of the following:

  • • Be a licensed pharmacist
  • • Complete the MHCP Pharmacist Enrollment Application (DHS-4668) (PDF) and include:
  • • Pharmacist license number
  • • Copy of diploma or Accreditation Council of Pharmacy Education (ACPE) program completion certificate
  • • The NPI number of the MHCP pharmacy or multidisciplinary setting (hospital or clinic) in which they will be providing MTMS. If the pharmacist practices in more than one location, provide NPIs for all locations
  • • A dated letter from the clinic or hospital administrator confirming employment if working in a multidisciplinary setting
  • • Have graduated from a college of pharmacy after May 1996 or passed a DHS approved Accreditation Council of Pharmacy Education (ACPE) program that has both didactic and clinical elements. To see a list of the approved courses, refer to the MHCP Pharmacy Program – Medication Therapy Management Education Requirements (PDF)
  • • Practice in a pharmacy or other place of business that meets the pharmacy privacy requirements or in an ambulatory care setting, such as a clinic or hospital, as part of a multidisciplinary team
  • • Have a structured patient care process allowing for assessment, development of a care plan and evaluation
  • • Use an electronic MTMS documentation system that is specifically designed to optimize the therapeutic outcomes of the patient’s medications
  • • Meet privacy and space requirements
  • Provider Type Home Page Links
    Review related Web pages for the latest news and additions, forms, and quick links.

    Enrollment Applications and Agreements

    MHCP Provider Enrollment forms are in Portable Document Format (PDF).

    Document ID Number

    Document Title

    DHS-4611A

    Provider Agreement: Individual Non Pay-To

    DHS-4668

    MHCP Pharmacist Enrollment Application

    DHS-3535

    MHCP Provider Information Change Form


    Enrollment as an individual pharmacist for MTMS is separate and distinct from enrolling as a pharmacy/clinic/hospital. If a pharmacy/clinic/hospital is already enrolled with MHCP, an individual pharmacist wishing to provide MTMS must enroll separately with MHCP.

    MTMS Privacy and Space Requirements (Business Setting)

    If the patient is receiving MTMS in a pharmacy, the pharmacy must meet privacy and space requirements. The pharmacy must keep a signed copy of the Medication Therapy Management Privacy/Space Requirements (DHS-6206) (PDF) on site. The consulting area must meet the following:

  • • Have sufficient size and accommodations to comfortably seat at least three people (two for interactive video) at a table
  • • Be private, so that when a typical patient is sitting or standing in the consulting area, the patient cannot be seen by others (including other patients, customers and employees)
  • • Be entirely devoted to enhancing patient outcomes and not used as a storage room for merchandise or other nonrelated items
  • • Be accessible to the patient without having to traverse through dispensing or storage areas
  • • Be enclosed sufficiently to prevent typical patient consultation conversation from being heard from other areas of the business
  • • Be enclosed sufficiently to prevent noise from other areas of the business to interfere with or distract from typical conversation in the consulting area
  • MTMS Patient Documentation

    Pharmacists must document each patient encounter. Documentation must include, but is not limited to the following:

    Patient information

  • • Recipient’s full, legal name
  • • Address and telephone number
  • • Gender
  • • Date of birth
  • • Current medical conditions
  • • Resolved medical conditions
  • • Allergies
  • • Primary physician and contact information
  • Other information may include the following (items are required if relevant):

  • • Date of encounter
  • • Location of patient if using interactive video
  • • Date of documentation
  • • Time spent with patient
  • • List of all prescription and nonprescription drugs with their indications
  • • List of drug doses, directions and intended use
  • • List of all relevant medical devices
  • • List of all dietary supplements, herbal products
  • • Alcohol and tobacco use history
  • • List of environmental factors that impact the patient
  • • Assessment of drug problems identified, including but not limited to:
  • • Determining that the medications are appropriately indicated
  • • Determining if the recipient needs additional medications
  • • Determining if the medications are the most effective products available for the conditions
  • • Determining if the medications are dosed appropriately to meet goals of therapy
  • • Identifying adverse effects caused by medications
  • • Determining if the medications are dosed excessively and causing toxicities
  • • Determining if the recipient is taking the medications appropriately to meet goals of therapy
  • • Evaluating effectiveness and safety of current drug therapy
  • • Written plan including goals and actions needed to resolve issues of current drug therapy
  • • Evaluation of success in meeting goals of medication treatment plan
  • • Information, instructions and resources delivered to the patient
  • • Content of pharmacist’s communications to patient’s other health care providers
  • Eligible Recipients

    MA and MinnesotaCare (fee-for-service and managed care) recipients are eligible for MTMS if they are all of the following:

  • • An outpatient (not inpatient or in an institutional setting)
  • • Not eligible for Medicare Part D
  • • Taking a prescription medication to treat or prevent one or more chronic conditions
  • Covered Services

    Medication therapy management services include the following:

  • • Performing or obtaining necessary assessments of the patient’s health status
  • • Face-to-face or interactive video encounters done in any of the following:
  • • Ambulatory care outpatient setting
  • • Clinics
  • • Pharmacies
  • • Recipient’s home if the patient does not reside in a skilled nursing facility
  • • Formulating a medication treatment plan
  • • Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness
  • • Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events
  • Documenting the care delivered and communicating essential information to the patient’s other primary care providers
  • • Providing verbal education and training designed to enhance patient understanding and appropriate use of the patient’s medications
  • • Providing information, support services, and resources designed to enhance patient adherence with the patient’s therapeutic regimens
  • • Coordinating and integrating medication therapy management services within the broader health care management services being provided to the patient
  • MTMS Delivered via Interactive Video (ITV)

    Qualified recipients who are more than twenty travel miles from an enrolled MHCP Medication Therapy Management Service provider may have the service delivered via interactive video to an ambulatory care site in which there is also no enrolled MTMS provider in the local trade area. Services must meet the following criteria:

  • • Both the patient site (origination site) and the pharmacist site (distant site) must be located in a pharmacy, clinic, hospital or other ambulatory care site.
  • • The originating site must meet the MTMS privacy and space requirements except that the space would need to seat only two people comfortably.
  • • Qualified recipients may have the service delivered via interactive video to their residence (origination site) if the service is performed during a covered home care visit by an MHCP enrolled provider.
  • • The pharmacist provider’s site (distant site) must be located in a pharmacy, clinic, hospital or other ambulatory care site.
  • All MTMS services delivered by interactive video must meet DHS requirements for equipment, privacy and billing:

  • • Interactive video includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient and the pharmacist
  • • The provider is responsible for supplying the equipment used for the service and the connection between the origination and distant sites. The provider may not use the recipient’s equipment or connection.
  • • Providers must use high quality interactive video and audio communication software and equipment. Equipment must be capable of displaying video full screen without reduced image quality or reliability and maintain a minimum download speed or transmission speed of 4 megabytes per second (Mbps). The video and audio must be synchronized.
  • • Providers must have procedures in place to prevent system failures that could lead to a breach in privacy or cause exposure of health records to unauthorized people.
  • • Interactive systems must be compliant with HIPAA privacy and security requirements and regulations.
  • • Billing providers must use modifier GT in conjunction with the applicable MTMS code(s) to signify that the service was delivered by ITV.
  • • The billing provider must use modifiers GT and place of service code 12 when the service is delivered via interactive video into the recipient’s residence.
  • Noncovered Services

  • • Encounters by telephone or by email
  • • Encounters in skilled nursing facilities
  • Billing

    MHCP will reimburse pharmacies, clinics and hospitals for MTMS only for face-to-face or ITV encounters and will base reimbursement on the lowest of five patient need levels, according to the following qualifying criteria:

  • • The number of medications the patient is currently taking (drug combination products are counted as one medication)
  • • The number of drug therapy problems the patient has at present
  • • The number of medical conditions for which the patient is currently being treated
  • Use the MN–ITS 837P (Professional) to bill claims to MHCP.

    The Pharmacist Services Technical Advisory Coalition has developed new HIPAA-compliant Medication Therapy Management CPT codes for pharmacists to bill Medicare and other third party payers for MTMS. MHCP is using these codes to reflect the estimated time to perform the service, as follows:

  • • 99605: A first encounter service performed face-to-face with a patient in a time increment of up to 15 minutes; $52.00
  • • 99606: Follow-up encounter use with the same patient in a time increment of up to 15 minutes for a subsequent or follow-up encounter; $34.00
  • • 99607: Additional increments of 15 minutes of time for 99605 or 99606; $24.00
  • The following table identifies the HIPAA-compliant CPT codes for providers to use based on the corresponding assessments, drug therapy issues, and care plans.

    HIPAA-compliant MTMS CPT Codes

    Level

    Assessment of Drug-related needs

    Identification of Drug Therapy Problems

    Complexity-of-Care Planning & FU Evaluation

    Approximate Face-to-Face Time

    Bill CPT Code

    Units

    Rate

    1

    Problem-focused - at least 1 medication

    Problem-focused - 0 drug therapy problems

    Straightforward – 1 medical condition

    15 min.

    99605 or 99606

    1 unit

    $52.00 or $34.00

    2

    Expanded Problem – at least 2 medications

    Expanded Problem – at least 1 drug therapy problem

    Straightforward – 1 medical condition

    16-30 min.

    99605 or 99606

    1 unit

    $76.00 or $58.00

    99607

    1 unit

    3

    Detailed – at least 3-5 medications

    Detailed – at least 2 drug therapy problems

    Low complexity at least 2 medical conditions

    31-45 min.

    99605 or 99606 and

    1 unit

    $100.00 or $82.00

    99607

    2 units

    4

    Expanded Detailed – at least 6-8 medications

    Expanded Detailed – at least 3 drug therapy problems

    Moderate Complexity – at least 3 medical conditions

    46-60 min.

    99605 or 99606 and

    1 unit

    $124.00 or $106.00

    99607

    3 units

    5

    Comprehensive –- 9 medications

    Comprehensive – at least 4 drug therapy problems

    High Complexity – at least 4 medical conditions

    60+ min.

    99605 or 99606 and

    1 unit

    $148.00 or $130.00

    99607

    4 units


    Example 1: Pharmacist performs MTMS for a new patient with four medications and two medical conditions, and identifies two drug therapy problems. Bill a Level 3 service:

    Claim line 1: 99605 1 unit
    Claim line 2: 99607 2 units
    Total reimbursement = $100

    Example 2: Pharmacist performs MTMS on existing patient with four medications and three medical conditions, and identifies one drug therapy problem. Note that the patient is placed at the lowest level where all three criteria are met. Bill a Level 2 service:

    Claim line 1: 99606 1 unit
    Claim line 2: 99607 1 unit
    Total reimbursement = $58.00

    Billing Limitations

    MHCP will reimburse for the following:

  • • Only face-to-face or interactive video encounters
  • • One CPT 99605 per provider per recipient in a 365-day period
  • • Up to seven CPT 99606 per recipient in a 365-day period
  • • Up to four CPT 99607 per recipient per date of service
  • Pharmacists should review the Fee-for-Service PA Criteria Sheet for MTMS for the (CPT 99606 only) before obtaining Prior Authorization for additional encounters.

    Billing Instructions

    Follow these instructions for billing:

  • • Submit claims using MN–ITS 837P
  • • Submit claims for recipients covered under a managed care organization (MCO), or a Prepaid Medical Assistance Program (PMAP), directly to the MCO/PMAP:
  • • Each MCO or PMAP may have MTMS programs with different/additional requirements
  • • Check with the specific MCO or PMAP for further details/additional MTMS compliance requirements
  • • Enter the pharmacist’s NPI number as the treating/rendering provider
  • • Enter the pharmacy, clinic, or hospital MHCP provider NPI number as the pay-to provider
  • • Enter HCPCS modifier GT if the service is delivered via interactive video
  • Additional Information and Resources

  • MN–ITS User Guide for MTMS
  • Pharmacy Services
  • • Medication Therapy Management Services (MTMS): (Chapter 326, Article 1, Section 31 section 256B.0625, subdivision 13h) - Scroll about half way down the page to view.
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