Analysis of Pharmacist Charges for Medication Therapy Management Services
Analysis of Pharmacist Charges for Medication Therapy Management Services
Purpose: Pharmacist charges for medication therapy management (MTM) services in an outpatient setting were analyzed.
Methods: Patients' visits with pharmacists in three ambulatory care clinics in a large, urban teaching institution from December 2005 through February 2006 were analyzed. Data collected included the number and type of current diseases, insurance coverage, number of medications patients were taking, pharmacist time spent per patient visit, pharmacy services provided, and estimated charge for services based on level of care provided using physician and pharmacist billing codes. Data were analyzed using descriptive statistics.
Results: A total of 500 pharmacist-patient visits were evaluated. The mean ± S.D. patient age was 59.0 ± 13.3 years. Patients had a mean ± S.D. of 4.0 ± 2.0 diseases and were taking 9.1 ± 4.6 medications. The majority of visits (83%) lasted 30 minutes or less. The mean charge per visit using incident-to physician care billing was $37.09 and $63.24 for level 1 and level 2 visits, respectively. Pharmacist billing was found to result in an average charge of $26.58 ($1 per minute), $53.16 ($2 per minute), or $79.72 ($3 per minute) per visit. There was no difference in pharmacist time spent with complex patients versus noncomplex patients ( p = 0.1314). The use of pharmacist billing codes would not be beneficial unless each visit was billed as $3 per minute.
Conclusion: Converting from incident-to physician billing to pharmacist billing would not generate additional revenue for this medical center at this time.
With the approval and implementation of the Medicare Modernization Act (MMA) on January 1, 2006, pharmacists were granted privileges to bill for cognitive services. On July 1, 2005, three Current Procedural Terminology (CPT) codes were approved for pharmacists to use when billing for medication therapy management (MTM) services. There are two base codes available: one for a new patient (0115T) and the other for a follow-up visit (0116T). These two codes are to be used when billing for the first 15 minutes of time spent with a patient. If the visit exceeds 15 minutes, an add-on code (+0117T) may be used for each additional 15-minute interval spent with the patient.
The main difference between the billing codes used by pharmacists and physicians' billing codes is that the billing codes for pharmacists do not account for the clinical complexity of the patient. Physicians' billing codes account for multiple aspects of a patient's visit, including patient history, physical examination, nature of the problem, medical decision- making, coordination of care, counseling, and time spent with the patient. Whereas pharmacists' billing codes are based on the amount of face-to-face time spent with a patient, physicians' billing codes are stratified by the level of complexity, ranging from level 1 (minimal severity and physician presence not required) to level 5 (moderate-to-high severity and high complexity). Table 1 illustrates the specific components of the most common billing codes used by pharmacists when billing incident-to physician care for a patient visit.
The definition of MTM services provided in the MMA is vague and does not give much direction to Medicare Prescription Drug Plan (PDP) sponsors or to pharmacists in developing MTM services. As a result, 11 prominent professional pharmacy organizations convened to develop a consensus definition of MTM services.
Shands Jacksonville Medical Center (SJMC) is a large, urban, teaching institution that provides a wide variety of inpatient and outpatient services. Ambulatory care pharmacists have been providing patient care services in collaboration with physicians for over 15 years and are responsible for over 8000 scheduled patient visits annually. The pharmacists have billed third-party payers for services incident-to physician care using the physicians' billing codes.
The purposes of this study were to characterize current pharmacy practice in ambulatory care clinics and to determine if the services provided meet the consensus definition of MTM services. The study also examined different billing methods.
Purpose: Pharmacist charges for medication therapy management (MTM) services in an outpatient setting were analyzed.
Methods: Patients' visits with pharmacists in three ambulatory care clinics in a large, urban teaching institution from December 2005 through February 2006 were analyzed. Data collected included the number and type of current diseases, insurance coverage, number of medications patients were taking, pharmacist time spent per patient visit, pharmacy services provided, and estimated charge for services based on level of care provided using physician and pharmacist billing codes. Data were analyzed using descriptive statistics.
Results: A total of 500 pharmacist-patient visits were evaluated. The mean ± S.D. patient age was 59.0 ± 13.3 years. Patients had a mean ± S.D. of 4.0 ± 2.0 diseases and were taking 9.1 ± 4.6 medications. The majority of visits (83%) lasted 30 minutes or less. The mean charge per visit using incident-to physician care billing was $37.09 and $63.24 for level 1 and level 2 visits, respectively. Pharmacist billing was found to result in an average charge of $26.58 ($1 per minute), $53.16 ($2 per minute), or $79.72 ($3 per minute) per visit. There was no difference in pharmacist time spent with complex patients versus noncomplex patients ( p = 0.1314). The use of pharmacist billing codes would not be beneficial unless each visit was billed as $3 per minute.
Conclusion: Converting from incident-to physician billing to pharmacist billing would not generate additional revenue for this medical center at this time.
With the approval and implementation of the Medicare Modernization Act (MMA) on January 1, 2006, pharmacists were granted privileges to bill for cognitive services. On July 1, 2005, three Current Procedural Terminology (CPT) codes were approved for pharmacists to use when billing for medication therapy management (MTM) services. There are two base codes available: one for a new patient (0115T) and the other for a follow-up visit (0116T). These two codes are to be used when billing for the first 15 minutes of time spent with a patient. If the visit exceeds 15 minutes, an add-on code (+0117T) may be used for each additional 15-minute interval spent with the patient.
The main difference between the billing codes used by pharmacists and physicians' billing codes is that the billing codes for pharmacists do not account for the clinical complexity of the patient. Physicians' billing codes account for multiple aspects of a patient's visit, including patient history, physical examination, nature of the problem, medical decision- making, coordination of care, counseling, and time spent with the patient. Whereas pharmacists' billing codes are based on the amount of face-to-face time spent with a patient, physicians' billing codes are stratified by the level of complexity, ranging from level 1 (minimal severity and physician presence not required) to level 5 (moderate-to-high severity and high complexity). Table 1 illustrates the specific components of the most common billing codes used by pharmacists when billing incident-to physician care for a patient visit.
The definition of MTM services provided in the MMA is vague and does not give much direction to Medicare Prescription Drug Plan (PDP) sponsors or to pharmacists in developing MTM services. As a result, 11 prominent professional pharmacy organizations convened to develop a consensus definition of MTM services.
Shands Jacksonville Medical Center (SJMC) is a large, urban, teaching institution that provides a wide variety of inpatient and outpatient services. Ambulatory care pharmacists have been providing patient care services in collaboration with physicians for over 15 years and are responsible for over 8000 scheduled patient visits annually. The pharmacists have billed third-party payers for services incident-to physician care using the physicians' billing codes.
The purposes of this study were to characterize current pharmacy practice in ambulatory care clinics and to determine if the services provided meet the consensus definition of MTM services. The study also examined different billing methods.