Overview
On Feb. 24, 2017, the Michigan Department of Health and Human Services (MDHHS) issued Medical Services Administration (MSA) Policy 17-09, pertaining to pharmacy claim reimbursement changes and coverage of pharmacist-provided MTM services. Pursuant to this policy, pharmacists are able to provide MTM services to Michigan Medicaid beneficiaries who are taking at least one medication for a chronic condition (effective April 1, 2017).
Medication Therapy Management (MTM) is, arguably, the cornerstone service of outpatient pharmacy clinical services. Leveraging the unique relationship between patients and their pharmacist, MTM has been shown to improve patient outcomes and reduce overall healthcare costs. While conducting a thorough review of all of a patient’s medications, the pharmacist is positioned to make a positive impact on that patient’s healthcare. Whether the pharmacist is identifying and resolving a drug-related problem, educating a patient about appropriate medication use or recommending a lifestyle change, the pharmacist can improve a patient’s health outcomes through MTM to ensure that long-term health adverse consequences are avoided.
Billing
MSA 17-09 defines MTM services as “face-to-face consultations provided by pharmacists to optimize drug therapy and improve therapeutic outcomes for beneficiaries.”3 Eligible patients enrolled in either fee-for-service (FFS), or any other Medicaid health plan (including managed care programs), are able to receive these services as a “carved-out” benefit reimbursed by Medicaid FFS. Patients who are eligible for MTM services under Medicare Part D are not eligible for MTM services under Michigan Medicaid. Patients who are enrolled in Medicare Part D are not eligible for MTM services under Michigan Medicaid.
Billing for Medicaid MTM services is done utilizing Current Procedural Terminology (CPT) Codes in the CHAMPS platform. It is important to note that processing claims through this system is significantly different from the processing of prescription claims. Pharmacy is unique in that prescription claims processing occurs in real time when prescription claims are submitted to a pharmacy benefit. Medical claims processing operates on a significantly different, and more delayed, timeframe. Note that these CPT codes are submitted by the Pharmacy provider, not the individual pharmacists conducting the intervention. The CPT codes for MTM services provided under this program are shown in the table below.
| CPT Code | Service | Reimbursement Rate |
|---|---|---|
| 99605 | Initial assessment performed face-to-face with a beneficiary in a time increment of up to 15 minutes | $50 |
| 99606 | Follow-up assessment of the same beneficiary in a time increment of up to 15 minutes | $25 |
| 99607 | Additional increments of 15 minutes of time for 99605 or 99606 | $10 |
Patients must be taking at least one medication for a recognized chronic condition to be eligible for these services. The table below identifies the disease states that would render a patient eligible for MTM services. Patient diagnoses should be documented using the ICD-10 format. See the resource compiled by MPA for a full list of eligible ICD-10 diagnosis codes.
| Alcohol Use Disorder | Heart Failure |
| Alzheimer’s Disease and Related Disorders or Senile Dementia |
Hemophilia |
| Anemia (including Sickle Cell Anemia) |
HIV |
| Atrial Fibrillation | Hypertension |
| Asthma | Ischemic Heart Disease |
| Bipolar Disorder | Lead Exposure |
| Cancer (all inclusive) | Liver Disease, Cirrhosis and Other Liver Conditions |
| Cataract | Obesity |
| Chronic Kidney Disease | Osteoporosis |
| Chronic Obstructive Pulmonary Disease & Bronchietasis |
Rheumatoid Arthritis/ Osteoarthritis |
| Cystic Fibrosis | Schizophrenia, Schizotypal, Delusional and other Non-Mood Psychotic Disorders |
| Deep Venous Thrombosis (while on anticoagulation)/Pulmonary Embolism (chronic anticoagulation) |
Stroke/Transient Ischemic Attack |
| Depression | Substance Use Disorder |
| Diabetes Mellitus | Tobacco Use Disorder |
| Glaucoma | Viral Hepatitis |
Pharmacist Intervention
According to MSA 17-09, MTM services covered under Michigan Medicaid include the following:
- Obtaining necessary assessments of the beneficiary’s health status
- Formulating a medication treatment plan
- Monitoring and evaluating the beneficiary’s response to therapy, including safety and effectiveness
- Performing a comprehensive medication review to identify, resolve and prevent medication-related problems, including adverse drug events
- Documenting the care delivered and communicating essential information to the beneficiary’s other primary care providers
- Referring the beneficiary to his primary care provider or specialist, if necessary
- Providing verbal education and training designed to enhance beneficiary understanding and appropriate use of medications
- Providing information, support services, and resources designed to enhance adherence with the beneficiary’s therapeutic regimens
- Providing an updated personal medication record and medication action plan for the beneficiary
- Coordinating and integrating MTM services within the broader healthcare management services being provided to the beneficiary
How to Get Started
Pharmacists seeking to enroll as MTM service providers for Michigan Medicaid must first obtain a National Provider Identification (NPI) number. NPI numbers can be applied for online through the National Plan Provider Enumeration System here.
Pharmacists will then need to enroll in the CHAMPS platform. The CHAMPS platform can be accessed online through the MILogin platform here.
References & Resources
- Michigan Department of Health and Human Services. MSA 17-09, Pharmacy Claim Reimbursement Changes and Coverage of Medication Therapy Management Services. Michigan Department of Health and Human Services website. http://www.michigan.gov/documents/
mdhhs/MSA_17-09_552843_7.pdf. Accessed on March 2017. - Roath E, Malburg D. Delivery of MTM Services for Michigan Medicaid Beneficiaries. Michigan Pharmacists Association website. https://www.michiganpharmacists.org/wp-content/uploads/2022/09/Delivery-of-MTM-Services-for-Michigan-Medicaid-Beneficiaries.pdf. Published April 2017.