An important part of medication therapy management (MTM) documentation is the paperwork needed to receive payment for MTM services. Pharmacists and pharmacy organizations have been working toward finding more opportunities to receive direct compensation for the time and professional expertise involved in MTM. Many studies have shown that MTM saves money in the long run, by preventing costly health and medication–related problems. Technicians can support a pharmacy MTM program by making sure that the proper documents are completed to receive payment. Currently, pharmacies and pharmacists may receive payment (either reimbursement or salary) for MTM from certain sources, such as those listed in Table 1.

BILLING FOR MTM UNDER MEDICARE PART D

The Centers for Medicare and Medicaid Services (CMS) require that pharmacists who wish to bill for MTM obtain a National Provider Identifier (NPI) number, available through an online application.¹ Pharmacies and organizations must maintain a separate NPI identifier from that of individual pharmacists. The link for this application is available at: https://nppes.cms.hhs.gov/NPPES.¹

Working with Medicare Part D sponsors

Unlike Medicare Parts A and B, Medicare Part D is privatized. This means that the government makes arrangements with payers or “sponsors” (such as health insurance companies) to provide services to Medicare Part D patients, instead of paying a physician or pharmacist directly. Medicare Part D sponsors are required to cover MTM services for eligible patients. The pharmacist or technician should consult with individual payers to determine whether they are contracted to provide Medicare Part D services and if so, how any MTM services should be billed. Usually, an arrangement is set between the Medicare Part D sponsor and the pharmacy and the fee amounts are determined in advance. Some payers have an online documentation system used for billing, and they require that the pharmacist (or billing representative, such as a technician) receive training in how to use that system.

Using CPT codes

If the payer uses a system involving Current Procedural Technology (CPT) codes, the current codes for MTM are as shown in Table 2.²

Unfortunately, much of the time spent on Medicare Part D MTM is not billable, including preparation, record gathering, and documentation. This is partly why having technicians assist with these steps is a more efficient way to conduct MTM.

THIRD–PARTY MTM VENDORS

Many health insurance and managed care companies subcontract with third–party MTM vendors. OutcomesMTM is an example of such a vendor. These organizations partner with pharmacists and other healthcare providers to target potential patients who may benefit from MTM services. Third–party MTM vendors might not use Current Procedural Technology (CPT) codes as part of their billing structure, and instead set specific fees to pay pharmacists for MTM services. These companies also have online billing systems.

HOSPITAL–BASED PROGRAMS

Readmission Reduction Programs

CMS penalizes hospitals for what they consider “excessive” readmissions for certain conditions under the Readmission Reduction Program. These penalties can add up to significant dollars lost by the institution if it does not achieve CMS standards.

Penalties are imposed if a patient is readmitted to the hospital within 30 days for treatment certain conditions, as outlined in Figure 1.³

Figure 1. Readmission Penalties³

Pharmacist–provided MTM services after hospital discharge may be part of hospitals’ strategies to reduce readmissions. To support this service, technicians may be asked to make calls to set up visits and collect medication lists.

CMS STAR Ratings Systems

Organizations such as insurance companies and managed care plans that sponsor Medicare Part C and D have become invested in MTM, because showing that they are offering MTM can help to increase their “STAR” rating. CMS STAR ratings are a way for these organizations to gain bonus payments from CMS if they receive a rating of 3 or more stars. Those with lower star ratings are flagged for potential termination of their CMS Medicare contracts. The STAR ratings show in Table 3.⁴

Although a goal of MTM services would be 25% to 40%, the latest reported numbers indicate that 8% to 11% of patients who are eligible for MTM under Medicare Part D receive these services.^5,6 STAR measures are looking at the total number of MTM encounters completed by the organization over the past two years. Pharmacy services are “triple–weighted,” meaning that improvements in these areas can account for significant funding for the organization. Thus some managed care plans and health insurance companies may invest in MTM services, as a way to directly improve their STAR ratings.

Contracting With Employer–Based Health Plans

Providing MTM services for local organizations, such as employer–based health services, can be a good way for a pharmacy to expand MTM opportunities. Many large employers, especially large corporations, have wellness programs aimed at reducing healthcare costs and increasing employee productivity.⁷ Pharmacists may contract with the employer to provide MTM (often in– house) for employees who are either targeted by the benefits department or who sign up voluntarily for the service.^8,9 If so, a billing system would be set up with the employer, most likely based on the number of employees and services who receive MTM.

CONCLUSION

Billing for MTM services is very specific to the organization that is providing the reimbursement. A pharmacy technician who is responsible for this role will need to receive training in billing systems for Medicare Part D sponsors, third–party vendors such as OutcomesMTM (if the pharmacy partners with them), and other possible payers. Keeping up with the billing is an important way to keep MTM services cost–effective for the pharmacy.

REFERENCES

1. National Plan & Provider Enumeration System. How to apply for an NPI. Available at: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
2. CPT Codes Lookup. American Academy of Professional Coders/American Medical Association. 2020. Available at: https://www.aapc.com/codes/cpt-codes-range/.
3. Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program (HRRP). Updated Aug 24, 2020. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.
4. Centers for Medicare & Medicaid Services. Five–star quality rating system. October 7, 2019. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS.
5. Rucker NL. Medicare Part D’s Medication Therapy Management: Shift from Neutral to Drive. AARP Public Policy Institute. Available at: medicare-part-d-shifting-from-neutral-to-drive-insight-AARP-ppi-health.pdf.
6. Few Medicare Beneficiaries Receive Comprehensive Medication Review Services. Avalere Insights & Analysis. Aug 7, 2014. Available at: https://avalere.com/insights/few-medicare-beneficiaries-receive-comprehensive-medication-review-services.
7. Johannigman MJ, Leifheit M, Bellman N, et al. Medication therapy management and condition care services in a community-based employer setting. Am J Health Syst Pharm. 2010;67(16):1362-1367.
8. Murawski M, Villa KR, Dole EJ, et al. Advanced-practice pharmacists: practice characteristics and reimbursement of pharmacists certified for collaborative clinical practice in New Mexico and North Carolina. Am J Health Syst Pharm. 2011;68(24):2341-2350.
9. Cranor CW, Christensen DB. The Asheville Project: factors associated with outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (Wash). 2003;43(2):160-172.