Pharmacist CPT Codes and Medication Therapy Management
Pharmacist CPT Codes and Medication Therapy Management
The following interview was conducted with Dr. Dan Buffington of Clinical Pharmacology Services, Inc., in Tampa, Florida, on the topic of the new Current Procedural Terminology (CPT) codes for pharmacist face-to-face medication therapy management (MTM) services. These codes are the first codes dedicated to pharmacists that have been recognized in the American Medical Association's CPT manual, and though they have not reached a category I status yet, they present the opportunity and means for pharmacists to bill for professional services with pharmacist-specific codes. Additional information can be obtained from the Pharmacist Services Technical Advisory Coalition at www.pstac.org.
Q: Can we use these new CPT codes for inpatient services?
A: The new CPT codes were designed to be applicable for all pharmacy practice environments and circumstances. The answer depends on whether payers include inpatient pharmacist services in their spectrum of covered benefits and whether the pharmacist is an employee of the institution or a private practitioner. If a payer recognizes inpatient pharmacist services as a separate billable service, the pharmacist should be able to use these codes and get reimbursed as per the agreement with the payer.
Q: Why do pharmacists need to get a National Provider Identifier (NPI) number?
A: By 2007, all health care providers, physicians, and allied health professionals will be able to obtain a national health care provider identification number. The new provider identification system is referred to as the NPI number. In order to be compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) when conducting electronic claims transactions, payers and insurers must use the NPI numbers. Both pharmacists and pharmacies must have NPI numbers if they wish to bill for products or clinical services. Starting October 2006, the Centers for Medicare and Medicaid Services (CMS) will require that an NPI number be included with all billing transactions along with the current CMS legacy identifier.
Q: Will pharmacists need to obtain a separate identifier with each payer?
A: No. The purpose of the NPI is to create a single unique identifier for every type of health care provider; by 2007, all health insurers will be required to use the new NPI for claims processing.
Q: A pharmacist described problems using the online NPI application system to register a business group of MTM pharmacists. One of the questions in the required information was the National Association of Boards of Pharmacy (NABP) number. If the group of pharmacists is not going to dispense medications, is an NABP number required?
A: No. According to Fox Systems, Inc., the CMS contractor responsible for the online NPI application process, an NABP number is not required. If you have a similar circumstance, you can use the Individual or Groups pathway from the National Uniform Claim Committee taxonomy (www.wpc-edi.com/taxonomy). Also, in section C of the application form, the information is optional, and in section D of the application, you can provide your tax identification number or leave the information blank. Contacting Fox Systems directly at (800) 465-3203 is still encouraged for additional guidance.
Q: If a patient initiates a request for MTM services, whom do I charge for the service?
A: If the patient is expecting the service to be covered under Part D, you need to ensure that he or she meets the plan's criteria for receiving MTM services, that the patient who initiated services is a member of a prescription drug plan (PDP), and if so, that you are recognized by that PDP as a provider. If the patient is not expecting the service to be covered under Part D, then it may be provided as a fee-for-service or under the patient's current insurance benefit.
Q: How can the new CPT codes be used for MTM services?
A: It is important to differentiate Medicare Part D MTM and MTM services as a general term and practice. At this point we do not know the design of all of the PDP's Part D MTM programs, but if plans contract with pharmacist providers for MTM, the new CPT codes are a HIPAA-compliant mechanism to communicate transactions for face-to-face MTM.
In reference to non-Part D MTM services, the new CPT codes can be used in billing transactions for services that are approved or covered by respective payers. At this time, it is not advisable to discontinue using "incident to" CPT codes until you have fully determined the frequency of a payer acceptance and rates for service billing processed with the new CPT codes. However, individual payers may dictate which codes they prefer and the circumstances for various types of codes.
Q: How can MTM be marketed to long-term-care (LTC) facilities and be distinguished from drug regimen review (DRR)?
A: This is being addressed more acutely through the LTC pharmacy groups. CMS is clear in its message that Part D MTM is not to be used in lieu of practices already required by law, such as patient counseling under the Omnibus Budget Reconciliation Act of 1990 and DRR. With this in mind, the establishment of standard of care will be key in any litmus test. Initially, the PDPs will help define this boundary since they are responsible for providing Part D MTM services to any recipient who has more than two covered medications, has multiple disease states, and is expected to spend more than $4000 in total covered prescription drug expenditures in a year. Pay close attention to updates from the various pharmacy organizations on experiences and recommended guidelines following the initiation of the Part D benefit.
Q: How will PDPs be held accountable for providing quality MTM services?
A: Since CMS has dictated that the cost of providing the Part D MTM service benefit is to emanate from the PDPs' administrative costs, we can anticipate that some plans may attempt to provide a minimum level of service to beneficiaries in the name of enhancing their profit margins. This is not in the best interest of the patient or CMS.
CMS, the National Quality Forum, the Agency for Healthcare Research and Quality, and other standard-setting organizations are actively working on cultivating the quality measures that will be used to gauge the MTM services and outcomes of the various PDPs. The effect of quality improvement organizations' (QIOs') efforts may only be seen after years of monitoring and reporting.
This represents an important time for pharmacists because there are numerous opportunities to support QIOs and assist in research initiatives that focus on MTM service-related outcomes.
Q: Will it be necessary to add the modifier-25 to the physician evaluation and management codes if a patient receives MTM services on the same day as a physician's visit?
A: Based on what we know about Part D MTM, a physician's visit on the same day that MTM services are provided would not matter since they are two distinct benefits (Part B and Part D), and they are provided by two different types of health care providers.
Q: What is the dollar value of the new CPT codes?
A: Individual pharmacists or group practices will determine their own fee structures and rates for services. Then, different payers, such as Part D PDPs or commercial health care plans, will establish payment guidelines and rates for services on a plan-to-plan basis.
The following interview was conducted with Dr. Dan Buffington of Clinical Pharmacology Services, Inc., in Tampa, Florida, on the topic of the new Current Procedural Terminology (CPT) codes for pharmacist face-to-face medication therapy management (MTM) services. These codes are the first codes dedicated to pharmacists that have been recognized in the American Medical Association's CPT manual, and though they have not reached a category I status yet, they present the opportunity and means for pharmacists to bill for professional services with pharmacist-specific codes. Additional information can be obtained from the Pharmacist Services Technical Advisory Coalition at www.pstac.org.
Q: Can we use these new CPT codes for inpatient services?
A: The new CPT codes were designed to be applicable for all pharmacy practice environments and circumstances. The answer depends on whether payers include inpatient pharmacist services in their spectrum of covered benefits and whether the pharmacist is an employee of the institution or a private practitioner. If a payer recognizes inpatient pharmacist services as a separate billable service, the pharmacist should be able to use these codes and get reimbursed as per the agreement with the payer.
Q: Why do pharmacists need to get a National Provider Identifier (NPI) number?
A: By 2007, all health care providers, physicians, and allied health professionals will be able to obtain a national health care provider identification number. The new provider identification system is referred to as the NPI number. In order to be compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) when conducting electronic claims transactions, payers and insurers must use the NPI numbers. Both pharmacists and pharmacies must have NPI numbers if they wish to bill for products or clinical services. Starting October 2006, the Centers for Medicare and Medicaid Services (CMS) will require that an NPI number be included with all billing transactions along with the current CMS legacy identifier.
Q: Will pharmacists need to obtain a separate identifier with each payer?
A: No. The purpose of the NPI is to create a single unique identifier for every type of health care provider; by 2007, all health insurers will be required to use the new NPI for claims processing.
Q: A pharmacist described problems using the online NPI application system to register a business group of MTM pharmacists. One of the questions in the required information was the National Association of Boards of Pharmacy (NABP) number. If the group of pharmacists is not going to dispense medications, is an NABP number required?
A: No. According to Fox Systems, Inc., the CMS contractor responsible for the online NPI application process, an NABP number is not required. If you have a similar circumstance, you can use the Individual or Groups pathway from the National Uniform Claim Committee taxonomy (www.wpc-edi.com/taxonomy). Also, in section C of the application form, the information is optional, and in section D of the application, you can provide your tax identification number or leave the information blank. Contacting Fox Systems directly at (800) 465-3203 is still encouraged for additional guidance.
Q: If a patient initiates a request for MTM services, whom do I charge for the service?
A: If the patient is expecting the service to be covered under Part D, you need to ensure that he or she meets the plan's criteria for receiving MTM services, that the patient who initiated services is a member of a prescription drug plan (PDP), and if so, that you are recognized by that PDP as a provider. If the patient is not expecting the service to be covered under Part D, then it may be provided as a fee-for-service or under the patient's current insurance benefit.
Q: How can the new CPT codes be used for MTM services?
A: It is important to differentiate Medicare Part D MTM and MTM services as a general term and practice. At this point we do not know the design of all of the PDP's Part D MTM programs, but if plans contract with pharmacist providers for MTM, the new CPT codes are a HIPAA-compliant mechanism to communicate transactions for face-to-face MTM.
In reference to non-Part D MTM services, the new CPT codes can be used in billing transactions for services that are approved or covered by respective payers. At this time, it is not advisable to discontinue using "incident to" CPT codes until you have fully determined the frequency of a payer acceptance and rates for service billing processed with the new CPT codes. However, individual payers may dictate which codes they prefer and the circumstances for various types of codes.
Q: How can MTM be marketed to long-term-care (LTC) facilities and be distinguished from drug regimen review (DRR)?
A: This is being addressed more acutely through the LTC pharmacy groups. CMS is clear in its message that Part D MTM is not to be used in lieu of practices already required by law, such as patient counseling under the Omnibus Budget Reconciliation Act of 1990 and DRR. With this in mind, the establishment of standard of care will be key in any litmus test. Initially, the PDPs will help define this boundary since they are responsible for providing Part D MTM services to any recipient who has more than two covered medications, has multiple disease states, and is expected to spend more than $4000 in total covered prescription drug expenditures in a year. Pay close attention to updates from the various pharmacy organizations on experiences and recommended guidelines following the initiation of the Part D benefit.
Q: How will PDPs be held accountable for providing quality MTM services?
A: Since CMS has dictated that the cost of providing the Part D MTM service benefit is to emanate from the PDPs' administrative costs, we can anticipate that some plans may attempt to provide a minimum level of service to beneficiaries in the name of enhancing their profit margins. This is not in the best interest of the patient or CMS.
CMS, the National Quality Forum, the Agency for Healthcare Research and Quality, and other standard-setting organizations are actively working on cultivating the quality measures that will be used to gauge the MTM services and outcomes of the various PDPs. The effect of quality improvement organizations' (QIOs') efforts may only be seen after years of monitoring and reporting.
This represents an important time for pharmacists because there are numerous opportunities to support QIOs and assist in research initiatives that focus on MTM service-related outcomes.
Q: Will it be necessary to add the modifier-25 to the physician evaluation and management codes if a patient receives MTM services on the same day as a physician's visit?
A: Based on what we know about Part D MTM, a physician's visit on the same day that MTM services are provided would not matter since they are two distinct benefits (Part B and Part D), and they are provided by two different types of health care providers.
Q: What is the dollar value of the new CPT codes?
A: Individual pharmacists or group practices will determine their own fee structures and rates for services. Then, different payers, such as Part D PDPs or commercial health care plans, will establish payment guidelines and rates for services on a plan-to-plan basis.