MTM Reimbursement and CPT Codes—Optimizing Revenue from Medication Therapy Management

MTM Reimbursement and CPT Codes—Optimizing Revenue from Medication Therapy Management

Untapped Revenue Potential in Medication Therapy Management

Not only do medication errors and improper medication management cost the U.S. economy more than $100 billion annually, but also only 15% of eligible people are provided with the MTM services. This gap poses an incentive for the providers who master MTM reimbursement strategies and build automated program-based service delivery systems.

MTM CPT Codes and Payment Structure

The reimbursement for MTM services begins with knowing the specific CPT codes created for payment for comprehensive medication management services. The reimbursement parameters are as follows:

99605 - Initial MTM Service: A comprehensive medication therapy review is done for the first 15 minutes for $65-85. This service provided by a pharmacist or a physician covers the arguments of a medication history review, medication-related problems, and a therapeutic recommendation formation.

99606 - Additional MTM Time: Payment for complex cases is given for $40-55 for each additional 15 mins. This code allows for better management of patients with multiple medications and a complex therapeutic regimen.

99607 - MTM Follow-up Services: This code covers the support for continual medication management by therapy evaluation, adherence checks, and educational patient engagement for $35-50 for each 15 mins.

Defining Eligible Patient Populations

MTM services are designed to meet the needs of specific patients that achieve the best reimbursement benefits while providing the most impactful clinical outcomes. In the case of MTM, Medicare Part D plans are required to provide MTM to beneficiaries with two or more chronic conditions, with two or more Part D covered medications, and annual medication costs of more than $4,279. These guidelines direct services to patients most likely to benefit from comprehensive medication management.

There is an increasing recognition of MTM services offered by private insurance companies, with favorable reimbursement rates available for clients diagnosed with diabetes, hypertension, hyperlipidemia, and other chronic conditions that require the use of multiple medications. Within the same frameworks, Medicaid managed care plans also offer MTM reimbursement for eligible patients.

Programmatic Implementation Innovation

Successful MTM programs require systematic methodologies for the identification of the patients, medication assessments, and continuous therapeutic assessments. Providers must have clear guidelines for identifying the appropriate patients, conducting comprehensive medication assessments, and capturing clinical activities to ensure maximum reimbursement levels.

In the medication therapy review process, the medication must also be evaluated for the following components: its appropriateness, effectiveness, safety, and adherence, if the medication is taken as prescribed. Providers have to recognize medication therapy concerns, evaluate therapeutic duplications, and provide evidence-based recommendations that improve the outcomes of the patients while decreasing healthcare costs.

Documentation Requirements for Maximum Reimbursement

The criteria for reimbursement of MTM services rely on thorough documentation substantiating medical necessity and the clinical value of services rendered. Required documentation includes thorough medication histories, assessment and identification of specific drug therapy problems (DTPs), therapeutic recommendations with clearly articulated clinical reasoning, and patient education relevant to the medication therapy management (MTM) services delivered.

Well-designed documentation systems track MTM services such as the clinician's work activities, the patient's reactions to the clinician's work, and the work completed in relation to the patient's medications. This information justifies reimbursement while substantiating the clinical effectiveness of medications optimized in relation to contracts with payers.

Technology Integration for MTM Success

MTM programs enhance technology systems that identify patients, automate medication reviews, conduct ongoing monitoring, and support other related activities. Integration of electronic health records (EHR) improves retrieval of patients’ medication histories and access to other relevant documents while offering clinical decision support systems that improve the quality of services.

Pharmacist collaboration platforms facilitate communication with other health care provider partners and with pharmacy partners, thereby reinforcing coordinated care that enhances clinical as well as reimbursement outcomes. These systems also generate comprehensive reports that demonstrate the program's effectiveness to both the payers and the practice administrator.

Revenue Optimization Through Population Health Management

The most successful MTM programs take a population health approach to identifying eligible patients and delivering services at scale. This entails creating patient risk stratification systems that preserve and defend valuable health care opportunities as well as ensure that all eligible beneficiaries receive appropriate care.

The automated patient outreach systems increase MTM uptake by informing patients of services and booking appointments for them. Using the phone and email and patient portals to communicate ensures that patients engage and make use of services.

Measuring MTM Program Success

An effective MTM program must demonstrate clinical and financial performance, which informs and optimizes value. Important performance indicators are medication use, clinically defined health outcomes for the patients, and patient revenue.

HealthArc’s Unified Care Management Platform makes it easier to carry out MTM by automatically finding patients, streamlining the medication review process, and tracking the results of all MTM services. Our platform enables MTM services to be carried out in an organized way, ensuring better payment and helping patients stick to their medications and achieve better health results through improved management of population health and teamwork between providers and pharmacists.