Medication Therapy Management Services (MTMS)
Revised: November 3, 2021
· Eligible Providers· Eligible Members· Covered Services· Noncovered Services· Billing· Additional Resources
Eligible Providers
To provide MTMS, pharmacists must enroll individually with Minnesota Health Care Programs (MHCP) and meet all of the following:
· Be a licensed pharmacist· Complete the MHCP Enrollment Application (DHS-4016) (PDF) and include:· Pharmacist license number· Copy of diploma or Accreditation Council of Pharmacy Education (ACPE) program completion certificate· Graduated from a college of pharmacy after May 1996 or passed a Board of Pharmacy 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)· 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
Enrollment Applications and Agreements
MTMS MHCP provider enrollment forms include the following:
· Provider Agreement: Individual Non Pay-To (DHS-4611A) (PDF)· MHCP Enrollment Application (DHS-4016) (PDF)· MHCP Provider Information Change Form (DHS-3535) (PDF)
Enrollment as an individual pharmacist for MTMS is separate and distinct from enrolling as a pharmacy, clinic or hospital. If a pharmacy, clinic or 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 member 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 used entirely for 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
· Member’s full, legal name· Address and telephone number· Gender· Date of birth· Current medical conditions· Resolved medical conditions· Allergies· Primary physician and contact information· Date of encounter· 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· Assessment of drug regimen and any drug-related problems identified, including but not limited to:· Determining that the medications are appropriately indicated· Determining if the member 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 member 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 member· Content of pharmacist’s communications to member’s other health care providers· Coordination, follow-up, and integration activities within the broader health care management services being provided to the member
Other information (items are required if relevant):
· Location of patient if using telehealth· Date of documentation· Alcohol and tobacco use history· List of environmental factors that impact the patient
Eligible Members
Medical Assistance (MA) and MinnesotaCare (fee-for-service and managed care) members 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 member’s health status· Face-to-face or telehealth encounters done in any of the following:· Ambulatory care outpatient setting· Clinics· Pharmacies· Member’s home or place of residence if the member does not reside in a skilled nursing facility· Formulating a medication treatment plan· Monitoring and evaluating the member’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 member’s other primary care providers· Providing verbal education and training designed to enhance member understanding and appropriate use of the member’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 member
MTMS Delivered via Telehealth
MTMS services delivered by telehealth must meet all state and federal requirements for equipment, privacy and billing, including the following:
· Telehealth systems must be compliant with HIPAA privacy and security requirements and regulations.· Billing providers must submit claims with the applicable MTMS codes and telehealth (telemedicine) identifiers to signify that the service was delivered by telehealth. Billing requirements for telehealth (telemedicine) services are described in the Physician and Professional Services section of the MHCP Provider Manual.· Providers must submit the Telemedicine Provider Assurance Statement (DHS-6806) (PDF) before billing for telehealth MTMS encounters.
Noncovered Services
· Encounters in the inpatient setting· Encounters in skilled nursing facilities· Encounters for MTMS for dual-eligible members
Billing
MHCP will reimburse pharmacies, clinics and hospitals for MTMS only for face-to-face or telehealth encounters 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 & Follow-up 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 and | 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:
· One CPT 99605 per provider per member in a 365-day period· Up to seven CPT 99606 per member in a 365-day period· Up to four CPT 99607 per member per date of service
Pharmacists should review the PA Criteria Sheet for MTMS before obtaining prior authorization for additional encounters.
Billing Instructions
Follow these instructions for billing:
· Submit claims using MN–ITS 837P· Submit claims for members covered under a managed care organization (MCO), or a Prepaid Medical Assistance Program (PMAP), directly to the MCO or PMAP· Each MCO or PMAP may have MTMS programs with different or additional requirements· Check with the specific MCO or PMAP for further details or additional MTMS compliance requirements· Enter the pharmacist’s NPI number as the treating or rendering provider· Enter the pharmacy, clinic or hospital MHCP provider NPI number as the pay-to provider
Additional Resources
MN–ITS User Guide for MTMS
Pharmacy Services
Minnesota Statutes 256B.0625, subdivision 13h (Medication Therapy Management Services)
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