All MTM services may be billed for, but the question remains: which insurance companies will reimburse them?
Let’s discuss the disruption of pharmacy care, as we know it, by evaluating the option of providing medication therapy management (MTM) services to a hospital’s inpatients and its associated medical groups' outpatients.
All MTM services may be billed for, but the question remains: which insurance companies will reimburse them? Many studies have validated the value of the pharmacist in providing MTM services solely as a cost-avoidance model for any specific medical group. Ideally, MTM services would be billed and reimbursed while cost-avoidance would be documented through an increasingly positive outcome of care for these specific patients.
MTM services may be focused on specific situations such as a targeted medication review or discharge education, or they may be provided as complete comprehensive medication reviews.
The following are general descriptions of the different forms of MTM services:
Comprehensive Medication Review
Target Medication Review
As Time Permits
Inpatient MTM Program
When implementing a bedside MTM program in an inpatient setting, the initial question that needs to be asked is whether the program is for all patients or just those who have the highest risk for readmission. In general, patients are very accepting of having a pharmacist sit with them for 30 to 60 minutes to discuss their home medication management, adherence tools, and medication education issues.
Quite often, unknown issues concerning other medications arise during these discussions, and the pharmacist may be able to resolve these issues just by being present and listening. These sessions are very effective when a patient is going home on a completely new medication for a newly diagnosed indication or postoperative treatment. This information may be addressed well in the first half of the bedside MTM service.
The second half is more challenging. The difficulty is that the discharge medication orders need to be written well ahead of discharge in order for a pharmacist to completely reconcile the medications prior to discharge. Usually, the physician comes in, performs rounds, and writes discharge orders, and then the patient is discharged.
At this point, patients do not want to wait for a pharmacist to come into their room to perform a comprehensive medication review; they would rather just go home. Without a policy in place to have discharge orders written at least 18 to 24 hours prior to discharge, it is difficult for a pharmacist to accomplish comprehensive medication reviews at discharge.
On the other hand, a 30-minute bedside MTM the evening prior to the expected discharge can go a long way in increasing patient satisfaction, educating patients and their family members about new medications and adherence tools, improving the outcome of therapy, and decreasing the chance for a medication-related readmission.
Outpatient MTM Program
On another level, MTM services could be provided through the hospital pharmacy to all high-risk patients associated with a particular medical group.
The hospital is an easy-to-access facility where patients could come for appointments with a pharmacist. The pharmacist may then provide a complete comprehensive medication review as described above. This would be a service that the hospital pharmacy would offer to all of the clinics associated with the particular medical group.
Medical records have plenty of data to help identify which patients are at the highest risk for admission or readmission. Patients may have been admitted to another local hospital for a serious medical condition, but because of their medical group affiliation, perhaps they were not offered MTM services at that hospital. Or, perhaps they were discharged after a new diagnosis and have a series of new medications.
We want to do all we can to help these patients understand their medication regimens in order to improve their outcomes and decrease their odds of readmission.
Complete MTM Program
Ideally, any MTM service provided by a hospital associated with a unique medical group would service both outpatients and inpatients. The pharmacist providing this service would perform a 30-minute bedside MTM with patients identified as having new medications or being at high risk for some specific reason.
The pharmacist would then follow up with the coordinator of the medical group to identify which outpatients are at the highest risk for admission or readmission due to medication-related problems. The MTM pharmacist would set up appointments with these patients to perform the comprehensive medication review in an office at the hospital, at their physician’s offices, or, in special circumstances, at the patients’ homes.
Billing for MTM Services
Currently, Medicare Part D recipients are the only individuals eligible for billable MTM services, though many third-party insurance companies are recognizing MTM services and reimbursing for them. That said, there are quite a few restrictions on which patients qualify for MTM service reimbursement.
The following is a short discussion that shows how complicated the MTM reimbursement process can be:
According to the 2015 Medication Therapy Management Program Guidance and Submission Instructions from the US Centers for Medicare and Medicaid Services, patients must have multiple chronic diseases, with 3 chronic diseases being the maximum number a Part D plan sponsor may require for targeted enrollment. Medicare Part D sponsors cannot require more than 3 chronic conditions in order for a member to be eligible for their MTM programs.
Changes under the MTMEA of 2015 would give Medicare Part D beneficiaries with only 1 of 4 specific chronic conditions potential access to MTM program services. These qualifying conditions include diabetes, cardiovascular disease, chronic obstructive pulmonary disease, and high cholesterol. In addition to being diagnosed with 3 or more chronic conditions, MTM-qualifying patients must also meet 2 other criteria. These requirements include taking multiple Part D drugs, with 8 being the maximum number a Part D plan sponsor can require for enrollment, as well as being likely to incur annual costs for covered Part D drugs greater than or equal to the specified 2015 MTM cost threshold of $3138.
In addition, 3 specific functions need to happen at the end of the MTM session in order for a pharmacist or other qualified health care provider to bill for a comprehensive medication review:
As of 2015, 3 new Current Procedural Terminology billing codes have been provided specifically for billing MTM services.
These codes are as follows:
Each and every time a complete comprehensive medication review is completed, a super-bill should be created and sent to the insurance company. Regardless of whether it is a Medicare Part D, HMO, or PPO, it is reasonable to send the bill and ask for reimbursement.
It is also important to note that a 30-minute bedside MTM would not qualify for billing under normal MTM reimbursement rules, unless the patient receives a printed and updated personal medication record, medication action plan, and documented follow up with his or her health care team.
In my opinion, the real financial benefit from a program such as this comes from cost-avoidance as well as client loyalty through patient satisfaction. Unfortunately, the evidence of these 2 criteria can only be measured through retrospective analysis.
Is it better to run an MTM program from within the facility using current staff or contract the program to an outside vendor? This is definitely a question for management to answer; however, there are a few items for pharmacists to consider.
First, after some experience with a program similar to this on an inpatient level, I discourage the idea of just trying to fit it into the normal duties of the staff pharmacist. Pharmacists are already incredibly busy, and adding these duties can lead to job resentment, as well a less-than-thorough MTM provision.
If the job of MTM provision is to be given to the staff hospital pharmacists, then every attempt should be made to allow for ample time to complete the tasks without overburdening staff with order entry duties.
Unlike some other pharmacist positions, provision of MTM services requires some serious bedside manner skills, including empathy, the ability to listen well, a good understanding of cultural barriers, and an ability to quickly change presentation format in order to meet learning needs of the client. In other words, any pharmacist may be able to learn the format, but interpersonal communication provides a definite advantage when looking for a positive patient experience.
Whether the position is hired or contracted, I feel that it should be a fixed position that is usually not rotated between pharmacists. This particular position may lend itself to a certain continuity of care that may be best served with one particular practitioner, and perhaps one relief practitioner. This type of position also lends itself to the option of “away” time.
In other words, if for some reason the pharmacist providing the MTM services is out for a week, it is not completely unreasonable that the MTM services would just not be offered for that week.
If the MTM position were a hired position, then it would be reasonable to make it such that the pharmacist is rotated through the weekend schedule to cover shifts and vacation; however, in order to maintain a reasonable MTM service, perhaps 75% to 80% of the pharmacist’s time would be focused on MTM provision.
If the MTM position were contracted, then clear channels of communication would need to be set up to provide communication between the contractor and the departments for which they were responsible. The institution hiring the contractor should have clear goals that it wants to achieve by bringing on such a contractor and define the direction that it wants the contracted pharmacist to pursue.
As you can tell, I have a passion for this particular corner of pharmacy. Back in 2012, I began studying and developing an MTM plan for the hospital where I work. After 18 months of planning, we were granted a 6-month trial to implement a bedside MTM program, which was successful.
One of the pharmacists from the outpatient setting would enter the hospital, review 60 to 70 charts for specific new medications, attend rounds for 1 hour as a discharge medication resource, and then follow up with 2 bedside MTM visits.
During these 4 hours, a pharmacist from the hospital would fill in at the outpatient pharmacy. The issue was that the outpatient pharmacy was decreasing its continuity of care with the hospital pharmacists that were rotating through.
After the 6-month trial, we came to the conclusion that we needed to hire a third outpatient pharmacist. This position would rotate into the hospital for 1 week every 3 weeks, providing 3 separate pharmacists with the opportunity to provide full-time bedside MTMs while also maintaining their skills as community pharmacists.
As an alternative plan, the new director of pharmacy chose to move the program to the inpatient pharmacy. As of today, the inpatient pharmacists are responsible for all of the order entry for their particular unit, as well as visiting a few patients on their floor each day to provide bedside MTM services. This practice has been sustained for nearly 12 months with success.
Knowing that MTM is here to stay, I attended the American Pharmacists Association MTM certification course this past summer. Since that time, I have started my own business in offering MTM services as a private practitioner.
Currently, I am seeing patients at one of our local retirement homes on a weekly basis. Two or 3 times a month, I visit the facility, meet with a patient, and perform a comprehensive medication review with that patient on a volunteer basis. This process is giving me some excellent practice at performing MTM, following up with the health care team, and understanding how it all fits together.
In the outpatient pharmacy where I work, I have also signed up with Outcomes MTM and Mirixa in order to provide Medicare Part D MTM services through an accepted outpatient platform. Although this practice is rewarding, I don’t have any assigned time to complete the process, so I fit it in between normal outpatient pharmacy duties.
If you have made it to this point in the article, then you are definitely interested in MTM. Please keep the process moving forward and disrupt your pharmacy!