(2023) Pharmacy Billing Guidelines – CPT 99605, CPT 99606 & CPT 99607

The CPT codes that are used to report Pharmacy services are 99605 CPT Code, 99606 CPT Code & 99607 CPT Code. Descriptions and billing guidelines can be found below.

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.

99605 CPT Code

Description of CPT 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 CPT Code

Description of CPT 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 CPT Code

Description of CPT 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)

Pharmacy Billing Guidelines

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

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

Pharmacy Billing Examples

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: CPT 99605 (1 unit)

Claim line 2: CPT 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: CPT 99606 (1 unit)

Claim line 2: CPT 99607 (1 unit)