Q&A: Billing for medication therapy management services

Q. The facility where I work will be charging for medication therapy management (MTM) services at its clinics. We have been told that the codes we will start seeing are G0463.1-5 based on 15-minute increments for Medicare and replacements as well as 99606.0 (initial visit) and 99607.0 (for each additional 15 minutes) for all other payers.

We will be billing these services under the ordering provider, and we should see a note from one of the pharmacists. However, I am wondering whether we should bill MTM services with a 1500 or UB-04 form.

A. If the pharmacist is employed by the hospital and clinic is a provider-based department of the hospital, then this could be covered as a hospital outpatient visit, provided it’s medically necessary and not simply preventative. In that case, the billing form should be UB-04 and the attending physician the account is registered to should be the ordering physician. The service must be ordered and meet other hospital incident to requirements such as direct supervision.

The code would likely be a clinic visit code G0463 and not the MTM CPT® codes, because the covered service would be visit incident to a physician’s service.

This is general guidance because there is still more to be verified with them. The pharmacist’s name is usually not on the claim because he or she cannot usually get a national provider identifier and the hospital is the billing provider not the pharmacist.

Editor’s note: This question was answered by Kimberly Anderwood Hoy Baker, JD, CPC, director of Medicare and compliance at HCPro, a division of BLR, in Middleton, Massachusetts.

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