Navigating Medication Therapy Management: Policies, Practices, and Identifying Potential Fraud, Waste, and Abuse
Medication Therapy Management (“MTM”) has been shown to improve overall health and well being. MTM programs typically involve comprehensive medication reviews, patient education, and ongoing monitoring to ensure effectiveness and safety. MTM has evolved, with pharmacists playing an integral role as part of interdisciplinary healthcare teams and MTM expanding into a standard practice in various healthcare settings, reflecting a shift toward patient-centered care.
Patients with chronic illnesses, such as diabetes, hypertension, or cardiovascular disease, often require multiple medications. The complexity of managing several prescriptions can lead to medication errors, adverse drug reactions, and non-adherence. The World Health Organization estimates that medication errors cost billions annually and contribute to substantial patient harm.
Below are the different aspects of MTM in the various lines of business.
Medicare
MTM was officially recognized by the federal government in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which requires Medicare Part D plans that offer prescription drug coverage to establish MTM programs (MTMPs) for eligible beneficiaries.
Medicaid
Medicaid, by contrast, does not have a nationwide mandate for MTM services; however some states include MTM as a covered benefit through Medicaid managed care organizations or state pharmacy programs. MTM coverage under Medicaid tends to vary widely between states in terms of eligibility, scope, reimbursement, and provider requirements. In some states, these services may be more limited or targeted to populations with specific needs.
Commercial Plans
In the private sector, MTM coverage is generally more variable and is often shaped by individual insurance plans. Unlike Medicare, private insurers are not federally required to offer a standardized MTM benefit. Instead, coverage decisions are at the discretion of each insurer. Some private plans view MTM as a value-added service particularly for members with chronic conditions or complex medication regimens offering comprehensive reviews, adherence support, and education, sometimes through collaborations with retail pharmacies or pharmacy benefit managers.
Coding Reference
Typically, MTM sessions should not exceed one hour per session. Additionally, limitations may vary by line of business; however, beneficiaries can expect at least one MTM comprehensive review per year and quarterly check-ins for targeted medication issues.
MTM Services CPT Codes and Descriptions
Table 1. contains the CPT codes and code descriptions utilized for MTM services
| CPT Code | CPT Code Description |
|---|---|
| 99605 | Medication therapy management service(s) provided by pharmacist, individual, face-to-face with recipient, with assessment and intervention if provided; initial 15 minutes, new recipient. |
| 99606 | Medication therapy management service(s) provided by pharmacist, individual, face-to-face with recipient, with assessment and intervention if provided, initial 15 minutes, established recipient. |
| 99607 | Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with recipient, with assessment and intervention if provided; each additional 15-minutes. |
Example Billing Elements for MTM Services
Table 2. contains billing examples for MTM services without and with add-on codes for the first 15 minutes and up to an hour
| Time | CPT Code | Billed Units | CPT Code | Billed United |
|---|---|---|---|---|
| 15 minutes or less | 99605 or 99606 | 1 | N/A | N/A |
| 16 – 30 minutes | 99605 or 99606 | 1 | 99607 | 1 |
| 31 – 45 minutes | 99605 or 99606 | 1 | 99607 | 2 |
| 46 – 60 minutes | 99605 or 99606 | 1 | 99607 | 3 |
How Fraud Scope Can Assist:
Understanding the scope of applicable federal, state, and commercial plan policies related to MTM services is essential in your review of potentially abusive billing. Of interest, Fraud Scope recently identified unusual utilization by place of service and from uncommon peer groups typically associated with MTM services. Fraud Scope’s pattern-based detection models, such as Suspicious Trends, Time Behavior, or Outlier Abuse, can assist in identifying outlier utilization, such as:
- Providers utilizing excessive number of services compared to their peers
- Providers utilization of place of service compared to their peers
- Providers utilizing excessive number of units compared to their peers
- Identification of moving trends for specific testing services compared to peers
Fraud Scope offers additional summary tools within Query Aggregates that can assist users with identifying outliers, including identifying providers whose claim composition and utilization is higher than peers by service.
References:
Medication Therapy Management: Current Challenges
https://www.tandfonline.com/doi/pdf/10.2147/IPRP.S179628
CMS: Medication Therapy Management
Medication Therapy Management | CMS
World Health Organization, Medication Without Harm
Comparison of Medication Therapy Management Services and Their Effects on Health Care Utilization and Medication Adherence