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CPT codes for Pharmacy Billing / Medication therapy management services

Since 2005, pharmacists have been able to use the codes 0115T, 0116T, and 0117T to record and seek reimbursement for interventions such as reviewing a patient’s history, creating a medication profile for a patient, and making recommendations to a patient for improving compliance with therapy. Effective January 1, 2008 three new CPT codes developed collaboratively by members of the Pharmacist Services Technical Advisory Coalition (PTSAC) replaced the above category III codes. The CPT codes that are used to report Pharmacy services and its full description are as follows

99605 Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient

99606 Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, established patient

+99607 Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service)

The billing of appropriate CPT codes involves Assessment of Drug-related needs + Identification of Drug Therapy Problems + Complexity-of-Care Planning & FU Evaluation + Approximate Face-to-Face Time

Five levels of pharmacy billing

Level 1: Problem-focused - at least 1 medication + Problem-focused - 0 drug therapy problems + Straightforward – 1 medical condition + 15 min.

You may bill CPT 99605 or 99606 (1 unit)

Level 2: Expanded Problem – at least 2 medications + Expanded Problem – at least 1 drug therapy problem + Straightforward – 1 medical condition + 16-30 min.

You may bill CPT 99605 or 99606 (1 unit) + 99607 (1 unit)

Level 3: Detailed – at least 3-5 medications + Detailed – at least 2 drug therapy problems + Low complexity at least 2 medical conditions + 31-45 min.

You may bill CPT 99605 or 99606 (1 unit)+ 99607 (2 units)

Level 4: Expanded Detailed – at least 6-8 medications + Expanded Detailed – at least 3 drug therapy problems + Moderate Complexity – at least 3 medical conditions + 46-60 min.

You may bill CPT 99605 or 99606 (1 unit) + 99607 (3 units)

Level 5: Comprehensive – 9 medications + Comprehensive – at least 4 drug therapy problems + High Complexity – at least 4 medical conditions + 60+ min.

You may bill CPT 99605 or 99606 (1 unit) + 99607 (4 units)

Pharmacy Billing tips

Example 1: Pharmacist performs MTMS for a new patient with four medications and two medical conditions, and identifies two drug therapy problems. Bill a Level 3 service:

Claim line 1: 99605 1 unit

Claim line 2: 99607 2 units

Example 2: Pharmacist performs MTMS on existing patient with four medications and three medical conditions, and identifies one drug therapy problem. Note that the patient is placed at the lowest level where all three criteria are met. Bill a Level 2 service:

Claim line 1: 99606 1 unit

Claim line 2: 99607 1 unit

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