Medication Therapy Management (MTM)

Eligibility

To provide MTM services, pharmacies must be contracted with PrimeWest Health and meet all of the following requirements:

1. Employ a licensed pharmacist
2. The licensed pharmacist must 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
3. Have a structured patient care process allowing for assessment and development of a care plan and evaluation
4. Use an electronic MTM service documentation system that is specifically designed to optimize the therapeutic outcomes of the member’s medications

MTM Services Privacy and Space Requirements (Business Setting)

If the member is receiving MTM services in a pharmacy, the pharmacy must meet privacy and space requirements. The consulting area must meet the following requirements:

1. Have sufficient size and accommodations to comfortably seat at least three people (two for interactive video) at a table
2. Be private, so that when a typical member is sitting or standing in the consulting area, the member cannot be seen by others (including other members, customers, and employees)
3. Be entirely devoted to enhancing member outcomes and not used as a storage room for merchandise or other nonrelated items
4. Be accessible to the member without having to traverse through dispensing or storage areas
5. Be enclosed sufficiently to prevent typical member consultation conversation from being heard from other areas of the business
6. 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 member encounter. Documentation must include, but is not limited to the following:

1. Patient information
   1. Recipient’s full, legal name
   2. Address and telephone number
   3. Gender
   4. Date of birth
   5. Current medical conditions
   6. Resolved medical conditions
   7. Allergies
   8. Primary physician and contact information
2. Other information (if applicable)
   1. Date of encounter
   2. Location of member if using interactive video
   3. Date of documentation
   4. Time spent with member
   5. List of all prescription and nonprescription drugs with their indications
   6. List of drug doses, directions, and intended use
   7. List of all relevant medical devices
   8. List of all dietary supplements and herbal products
   9. Alcohol and tobacco use history
   10. List of environmental factors that affect the member
   11. Assessment of drug problems identified, including but not limited to the following:
       1. Determining that the medications are appropriately indicated
       2. Determining if the member needs additional medications
       3. Determining if the medications are the most effective products available for the conditions
       4. Determining if the medications are dosed appropriately to meet goals of therapy
       5. Identifying adverse effects caused by medications
       6. Determining if the medications are dosed excessively and causing toxicities
       7. Determining if the member is taking the medications appropriately to meet goals of therapy
       8. Evaluating effectiveness and safety of current drug therapy
       9. Written plan including goals and actions needed to resolve issues of current drug therapy
       10. Evaluation of success in meeting goals of medication treatment plan
       11. Information, instructions and resources delivered to the member
       12. Content of pharmacist’s communications to member’s other health care providers

Eligible Recipients

Medical Assistance and MinnesotaCare members are eligible for MTM services if they are:

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

Covered Services

MTM services include:

1. Performing or obtaining necessary assessments of the member’s health status
2. Face-to-face or telehealth/interactive video encounters done in:
   1. Ambulatory care outpatient setting
   2. Clinics
   3. Pharmacies
   4. Recipient’s home (if the member does not reside in a Skilled Nursing Facility [SNF])
3. Formulating a medication treatment plan
4. Monitoring and evaluating the member’s response to therapy, including safety and effectiveness
5. Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events
6. Documenting the care delivered and communicating essential information to the member’s other primary care providers
7. Providing verbal education and training designed to enhance member understanding and appropriate use of the member’s medications
8. Providing information, support services, and resources designed to enhance member adherence with the member’s therapeutic regimens

MTMS Delivered via Telehealth

Qualified members who are more than 20 travel miles from an enrolled PrimeWest Health MTM services provider may have the service performed via telehealth when the following are met:

1. The pharmacy site (distant site) must be located in a pharmacy, clinic, hospital, or other site that meets privacy and space requirements
2. The originating site must meet the MTM services privacy and space requirements except that the space would need to comfortably seat only two persons
3. Billing provider will use modifier GT in conjunction with the applicable MTM services code(s) to signify that the service was delivered by telehealth
4. 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.
5. Interactive systems must be compliant with HIPAA privacy and security requirements and regulations.

Noncovered Services

1. Encounters in SNFs
2. Encounters in the inpatient setting
3. Encounters for MTM services for dual-eligible members

Billing

PrimeWest Health will reimburse pharmacies, clinics, and hospitals for MTMS only for face-to-face, telephonic, or telehealth encounters and based on the lowest of five member need levels, according to the following qualifying criteria:

1. The number of medications the patient is currently taking (drug combination products are counted as one medication)
2. The number of drug therapy problems the patient has at present
3. The number of medical conditions for which the member is currently being treated

Bill claims to PrimeWest Health.

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 MTM services. PrimeWest Health is using these codes to reflect the estimated time to perform the service, as follows:

1. 99605: A first encounter service performed face-to-face with a patient in a time increment of up to 15 minutes
2. 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
3. 99607: Additional increments of 15 minutes of time for 99605 or 99606

The following table identifies the HIPAA-compliant CPT codes for providers to use based on the corresponding assessments, drug therapy issues, and care plans.

Example 1: Pharmacist performs MTM services for a new member 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

Example 2: Pharmacist performs MTM services on an existing member with four medications and three medical conditions, and identifies one drug therapy problem. Note that the member 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

Billing Instructions

1. Submit claims using code 837P
2. Enter the pharmacist’s NPI number as the treating/rendering provider
3. Enter the pharmacy/clinic/hospital provider NPI number as the billing provider
4. Enter HCPCS modifier GT if the service is delivered via telehealth

PrimeWest Health facilitates an MTM program policy for its F&C, MinnesotaCare, MSC+, and SNBC populations in accordance with its DHS contract. MTM is a pharmacist-focused initiative to educate patients with complicated medication regimens in hope of achieving better outcomes. The program is for any PrimeWest Health member in Medical Assistance (Medicaid), MinnesotaCare, or MSC+ programs who has one or more chronic conditions being treated with three or more prescriptions per month. No prior authorizations are required to perform this service to a PrimeWest Health member, but all providers need to be contracted with PrimeWest Health in order to be reimbursed for their service time. Any pharmacist interested in performing this service to eligible PrimeWest Health members should contact the Provider Contact Center at 1-866-431-0802 (toll free) for details.

The Medicare prescription drug benefit provided through MedImpact includes MTM services for all Part D members in PrimeWest Health. The majority of the program is administered through a call center, but DUR edits may appear during claim processing that require a pharmacist’s services.

References

MN Stat. sec. 62Q.676 – Medication Therapy Management

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Updated_09/06/2023