Integrating Technicians in Reimbursement Requires Understanding CPT Codes

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By empowering pharmacy technicians to actively participate in billing and reimbursement processes, health care practices can streamline operations, mitigate billing errors, and optimize revenue generation.

In today's rapidly evolving health care ecosystem, medication therapy management (MTM) stands out as a cornerstone of patient care. Within this landscape, the role of pharmacy technicians transcends traditional boundaries, evolving into critical support pillars for MTM services. By synergizing their expertise with pharmacists, pharmacy technicians wield significant influence over the optimization of billing practices and the precision of reimbursement processes within MTM. This strategic alignment not only heightens operational efficiency but also serves as a catalyst for maximizing revenue streams within healthcare practices.

Pharmacist uses a service fee calculator to calculate drug reimbursement, financials

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Central to the integration of pharmacy technicians in billing and reimbursement is a comprehensive understanding of relevant Current Procedural Technology (CPT) codes. Codes such as 99605, 99606, and 99607 delineate the scope of MTM services provided by pharmacists, allowing for accurate documentation and billing for these essential clinical interventions. A few key CPT codes are outlined below1:

CPT Code 99605: MTM Service(s) Provided by a Pharmacist, Individual, Initial 15 Minutes Face-to-Face with the Patient

This code signifies the provision of comprehensive medication therapy management services by a pharmacist during an initial 15-minute face-to-face encounter with the patient. Pharmacy technicians play a vital role in supporting pharmacists during these interactions by assisting with patient intake, data entry, and administrative tasks to ensure seamless delivery of care.

CPT Code 99606: Medication Therapy Management Service(s) Provided by a Pharmacist, Individual, Initial 15 Minutes Face-to-Face with the Patient; Additional 15 Minutes

For extended MTM sessions exceeding the initial 15 minutes, CPT code 99606 allows pharmacists to bill for each additional 15-minute increment of patient interaction. Pharmacy technicians contribute to this process by facilitating documentation, updating patient records, and assisting with follow-up communications, thereby optimizing workflow efficiency and ensuring accurate billing for extended services.

CPT Code 99607: Medication Therapy Management Service(s) Provided by a Pharmacist, Individual, Initial 15 Minutes Face-to-Face with the Patient; Additional 15 Minutes (List Separately in Addition to Code for Primary Procedure)

When billing for additional medication therapy management services provided beyond the primary procedure, CPT code 99607 is listed separately to indicate the allocation of extra time spent by the pharmacist in patient care activities. Pharmacy technicians support this billing practice by meticulously documenting the duration and nature of pharmacist-patient interactions, ensuring compliance with coding guidelines, and maximizing reimbursement opportunities.

MTM Pharmacist Pilot: Reimbursement Guidelines

The MTM reimbursement guidelines in Tennessee offer a structured framework for compensating health care providers for covered services. The key components of the reimbursement guidelines are listed below2:

Case Rates for MTM Covered Services

The reimbursement rates for MTM services are categorized based on the targeted disease states and the level of risk associated with the patient. These rates are as follows2:

  • Targeted Disease States (Juvenile Asthma or Diabetes): Modifier U1 - $55.00 for 2 Months
  • Medium-High Risk: Modifier U2 - $55.00 for 3 Months
  • Critical, High Risk: Modifier U3 - $75.00 for 6 Months
  • Exceptions: Modifier U4 - Rate based on level of care, subject to appropriate approval

CPT Codes, Descriptions, and Billing Process

The following CPT codes are utilized to indicate the services provided to the member:

  1. 99605: New patient visit, initial 15 minutes
  2. 99606: Established patient visit, initial 15 minutes
  3. 99607: Add-on code for each additional 15-minute increment
  4. 98966-98968: Telephone assessment and management services provided by a qualified nonphysician health care professional to an established patient

Pharmacists bill the appropriate CPT code along with the service modifier to receive the appropriate case rate reimbursement. If a visit exceeds 15 minutes, pharmacists also submit 99607 for each additional 15-minute increment. However, it is important to note that CPT code 99607 is for informational purposes only and does not impact claims payment.

Exception Handling

Pharmacists must complete and upload an MTM exception (ME) form to the Care Coordination Team for any service limit exceptions. Claims submitted beyond the risk-based maximum limit may be subject to recoupment unless an ME form is submitted and reviewed for completeness by the Managed Care Organizations.

Other Considerations

Only one case rate payment is made per member per month based on the pharmacist who submits the first claim for the billing month. If a member switches pharmacists during treatment, the service limit follows the member. Members who change risk categories are eligible for service limits equal to the higher risk service payment limit. Finally, claims must be submitted within the timely filing guidelines outlined in the provider administration manual.

Maximizing Pharmacy Technician Involvement for Optimal Reimbursement

By empowering pharmacy technicians to actively participate in billing and reimbursement processes, health care practices can streamline operations, mitigate billing errors, and optimize revenue generation. Training programs tailored to pharmacy technicians' roles in documentation, coding, and compliance foster a culture of accountability and excellence, ultimately enhancing the financial viability and sustainability of health care practices.

Incorporating pharmacy technicians into billing and reimbursement processes not only enhances operational efficiency but also fosters a culture of collaboration and excellence, driving positive outcomes for patients and health care practices alike. Through strategic utilization of CPT codes and effective training initiatives, pharmacy technicians can contribute significantly to the financial success and clinical excellence of their organizations in today's dynamic health care landscape.

Moreover, face-to-face services eligible for reporting during MTM visits encompass a range of activities critical to patient care and medication management. These include comprehensive medication reviews, medication counseling, adherence support, disease state management, health promotion, prevention, and follow-up monitoring. Pharmacy technicians play a crucial role in supporting pharmacists in these activities, ensuring accurate documentation of time spent on each service to optimize billing practices and reimbursement accuracy within the MTM program.

References

1. American Medical Association. (2023). Current Procedural Terminology (CPT) 2023. Chicago, IL.

2. Medication Therapy Management Program. Tennessee Division of TennCare. Accessed May 2, 2024. https://www.tn.gov/tenncare/providers/managed-care-contractors/pharmacy-benefits-manager/medication-therapy-management-pilot-program.html

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