National Billing Codes Announced for Pharmacists' Services
Come New Year's Day 2006, pharmacists will have three nationally recognized codes to bill third-party payers for medication therapy management (MTM) services.

Current Procedural Terminology (CPT) codes 0115T, 0116T, and 0117T describe pharmacist-provided MTM services and recognize the initial face-to-face encounter, subsequent visits, and any appointment lasting beyond 15 minutes (see sidebar).

The three codes were released to the public on July 1, and pharmacists can start using them January 1, said Michael Beebe, secretary of the group that issues CPT codes.

One portion of the far-reaching Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the Department of Health and Human Services to simplify the administration of Medicare and Medicaid and enable payers and health care providers to efficiently transmit electronic claims data.

The department in 2000 adopted Current Procedural Terminology (CPT), Fourth Edition, published by the American Medical Association (AMA), as the standard for electronic transmission of data codes for physicians' and other health care professionals' services.

For health care providers, this standard meant that they would need to know only one code for a particular service rather than contact each payer to find out its code. Also, with the standard in effect, a health plan could not legally delay processing or reject an electronic claim solely because it lacked the plan's code for a particular service.

The National Community Pharmacists Association, said Holly Whitcomb Henry, chair of the Pharmacy Services Technical Advisory Coalition and a member of the association's executive team, saw the HIPAA regulation on electronic transaction standards as an avenue for getting nationally recognized billing codes for pharmacists' services.

Henry said her association contacted other national pharmacy organizations, including ASHP, to form the technical advisory coalition in 2002.

The coalition's first accomplishment, she said, was to get a pharmacist on the CPT editorial panel's Health Care Professionals Advisory Committee.

That pharmacist was Daniel Buffington, practice director of Clinical Pharmacology Services Inc. in Tampa, Florida, and one of three ASHP members representing the Society in the coalition.

Although the pharmacist-specific CPT codes bear the title "medication therapy management," a service that some Medicare Part D enrollees will receive, the codes "are really meant to articulate pharmacy services in general, regardless of the payer type or practice setting," Buffington said.

"The CPT editorial panel themselves struggled making sure that what was produced in terms of coding was not to be confused as being limited to a Medicare Part D beneficiary," he said, referring to enrollees in the new prescription drug benefit.

In trying to secure the CPT codes, the pharmacy coalition had presented the CPT editorial panel with the definition of MTM services that ASHP and 10 other pharmacy professional organizations had developed and provided to the Centers for Medicare and Medicaid Services, Buffington said.

The editorial panel edited the 194-word definition down to something that is still longer than the usual description for a CPT code.

According to the editorial panel, MTM provided by a pharmacist is a face-to-face assessment or intervention with a patient to improve the person's response to medications and avoid potential drug-related complications. This service is separate and distinct from providing product-specific information when dispensing a medication to a patient.

The editorial panel also explained the documentation that pharmacists must maintain to support their claim of having provided the service: a review of the patient's medical history, a description of the patient's chief complaint or concern, a medication profile of prescription and nonprescription drug use, and recommendations for improving the patient's response to medications and level of therapy adherence.

The T in 0115T, 0116T, and 0117T means that the CPT editorial panel deemed pharmacist-provided MTM an emerging service and assigned it temporary codes in what is known as category III.

"We have a five-year sunset on category III codes," said Beebe of the CPT editorial panel. "The thinking is that if after five years the technology has not panned out the way we thought it would, the service has changed. We will sunset the code... We'll no longer publish it."

Before making any category III codes permanent listings, he said, the editorial panel would want to know, for example, how the codes are being used and who is using them.

"In this case," Beebe said, "there was a lot of uncertainty on the part of the panel and the payers who sit on the panel [about] how the code would be used, whether it would be paid, how it would be paid, [and] if it would just be used for data collection."

The CPT editorial panel has 17 members, nearly all physicians, including a representative from American Health Insurance Plans and another from Blue Cross Blue Shield Association.

Beebe said the pharmacy coalition that initially proposed the CPT codes would probably be the group responsible for submitting the follow-up application "after a couple years of data collection."

Temporary CPT codes have existed since around 2002, Beebe said. At least seven have received permanent status, moving up to category I.

"It's not a guarantee, but it's something... that's done regularly," he said.

David Chen, ASHP's staff liaison to the pharmacy coalition, said the Society has mixed feelings about the editorial panel's decision.

While pleased that pharmacists now have CPT codes that describe a patient care service, Chen explained, ASHP disliked assignment of the codes to category III, necessitating data collection and another presentation to the editorial panel.

"But this is a big step forward for the profession," he said. "We've been recognized now formally by the AMA as a provider for MTM services, and, in addition to that, we now have codes that will be HIPAA compliant."

Buffington cautioned pharmacists against assuming that CPT codes guarantee payment for services.

"You have to become a provider with the given payer first" before submitting claims for MTM services, he said.

The three pharmacist-specific CPT codes, he said, can be used by pharmacists who have a contract or an agreement with a third-party payer to provide MTM services.

Buffington described his own experience in getting paid for providing MTM services. "Some of the patients that we see are managed care, and we'll get approval on a case-by-case basis. There's no contract. You get approval through either prior authorization or the medical department."

Henry, a coowner of RxTra Care Inc., a group of four community pharmacies in Seattle, Washington, said she plans to use the new CPT codes once she contracts with Medicare Part D prescription drug plan sponsors.

Patients, Henry said, now pay her directly for MTM services and submit receipts to their insurance companies.

"The two basic codes... are intended to bill for any time you spend with the patient up to 15 minutes," Henry said in describing 0115T and 0116T. "If you have a 16-minute encounter, then you're entitled to use the modifier [0117T] and bill for another 15 minutes. So if it's a 20-minute encounter, then you would use that modifier."

But to bill third-party payers with CPT codes, Henry said pharmacists must also know the HIPAA-compliant diagnosis codes in the International Classification of Diseases, 9th Edition, Clinical Modification and their "place of service" code, which is 01 for pharmacies.

And by May 23, 2007, she said, pharmacists would have to use an individual national provider identifier, although a payer could require this HIPAA-compliant identification earlier.

The documentation described in the pharmacist-specific CPT codes "stays in-house with the pharmacist," Henry said. Only if a payer questions the bill or conducts an audit would a pharmacist need to show documentation, she said.

Chen said ASHP will continue to support the coalition's activities, which include educating health care providers and payers and deciding how the pharmacy group will collect the information needed to move the profession's CPT codes to category I.

ASHP will also work on educating members, he said, through a workshop at the Midyear Clinical Meeting in December 2005 and at least one conference call.

In addition to Buffington and Chen, ASHP's representatives in the coalition are Andrew Wilson, pharmacy director at the Medical College of Virginia Hospitals in Richmond, and Mark J. Kliethermes, supervisor of information systems for ambulatory care pharmacy at the University of Illinois at Chicago College of Pharmacy and spouse of an ambulatory care pharmacy manager (see the next News article).