Medication Therapy Management

• Medication Therapy Review is a systematic process of collecting patient‐specific information, assessing medication therapies to identify medication‐related problems, developing a prioritized list of medication‐related problems, and creating a plan to resolve them
• Personal Medication Record is a comprehensive record of the patient’s medications
• Medication‐Related Action Plan is patient‐centric document containing a list of actions for the patient to use in tracking progress for self‐management
• Intervention and/or Referral consists of the pharmacist providing consultative services & intervening to address medication‐related problems; when necessary, the pharmacist refers the patient to a physician or other healthcare professional
• Documentation & Follow‐Up consists of medication therapy management services documented in a consistent manner, and a follow‐up medication therapy management visit is scheduled based on the patient’s medication-related needs, or the patient is transitioned from one care setting to another

• Must have a National Provider Identification Number (NPI) to bill Medicare. If billing Medicare, cannot provide free or reduced services to other patients as this is considered Medicare fraud. To view Medicare billing information, click here. To view Medicare standard format guidelines, click here.
• Click here to view the three billing codes.
• Contact payers to determine: whether they will cover medication therapy management services, what their eligibility requirements are, whether they require medication therapy management certification for reimbursement and whether they require a specific contract for reimbursement of medication therapy management services.
• Billing for Medication Therapy Management Services
• Most Medicare patients are eligible for an annual Comprehensive Medical Review.
• Some Louisiana Medicaid Managed Care Organizations reimburse for MTM services.
• Some private payers in Louisiana reimburse for MTM services.
• OutcomesMTM is a preferred referral platform for many of these insurers.

1. Identify a Project Champion
   1. Do you have leadership support?
   2. What other partners do you need involved?
   3. Are there resources such as grants or trainings available?
2. Define your goals
   1. How will this enhance/support your current services?
   2. How will you assess/define success?
   3. How will this increase opportunity for your pharmacy team?
      1. Leverage pharmacy technicians
3. Establish a Business Plan
   1. Define your revenue model
      1. Cost-benefit or revenue based
   2. Conduct outreach to necessary primary care partners, employers, or other key partners needed for coordinated services
4. Create a financial plan
   1. Expected outcomes (savings/revenue generated)
   2. Any necessary Business Agreements
5. Implementation strategy
   1. Patient selection
   2. Appointment scheduling
   3. Patient visit
   4. Documentation
   5. Follow-up
6. Evaluation Strategy
   1. Defining success
      1. How will you demonstrate the impact of your program on patient outcomes?
      2. How will you demonstrate the financial success of your program?

• Establish and maintain a pharmacist-patient relationship. The physician is required to be geographically located so that the physician, or a back-up physician, is able to be physically present daily to provide medical care to a patient subject to collaborative drug therapy management.
• Provide a status updated document in the patient’s medical record at least quarterly regarding problems, complications, and noncompliance. On a scheduled basis no less than every three months, receive a status report on the patient including, but not limited to any problem, complication or other issues relating to patient non-compliance with drug therapy management. This requirement may be met by entering the information in the patient’s medical record.
• The Patient medical record must include:
  
  • Their prescription or order implementing drug therapy management and any subsequent orders or sets
  • Documentation of annual review and quarterly periodic reports provided by the pharmacist
  • Consultation and reports
  • Documentation of patient’s informed consent
• The Pharmacist must be available to patient via telecommunication if needed. Physician must be available through direct telecommunication for consultation, assistance, and direction.
• Patient must have an established physician-patient relationship including a face-to-face visit.
• Pharmacist’s ability to initiate, discontinue, and substitute medications will be described in the practice agreement.
• Order set incorporating patient specific variations. Copy of the order set shall be provided to the pharmacists and included as part of the patient’s medical record. Order set must include at a minimum:
  
  • Contact information, including phone number, for pharmacist and provider
  • Patient name, address, gender, date of birth, phone number
  • Disease or condition to be managed
  • Disease specific drugs to be utilized
  • Type and extent of drug therapy management physician authorizes the pharmacist to perform
  • Specific responsibilities of physician and pharmacist
  • Procedures, criteria, or plan the pharmacist is required to follow
  • Specific tests related to drug therapy management authorized by the physician for order and evaluation
  • Reporting and documentation requirements
  • Conditions and events up on with notification of collaborating provider are required and
  • Procedures for immediate consultation between pharmacist, provider, and/or patient.

• Pharmacist and physician must be licensed to practice in Louisiana without restrictions.
• Pharmacy must complete an application through the Board of Pharmacy. Registration must be renewed annually and the board must be notified if there are new physician collaborators not named in the original collaborative drug therapy management.
• Documentation and notification requirements.
• Written consent from the patient is required.
• The physician must:
  
  • Inform the patient of the collaborative nature of collaborative drug therapy management for the patient’s specific medical disease or condition and provided instructions and contact information for follow-up visits with the physician and pharmacist
  • Inform the patient that he or she may decline to participate in a collaborative drug therapy management practice and may withdraw at any time without terminating the physician-patient relationship
  • Provide written disclosure of any contractual or financial arrangement with any other party that may impact one of the party’s decisions to participate in the agreement
  • Have an agreement maintained and available upon request and
  • Have an agreement that is only valid for up to one year.

Scope of services are limited to:

• Monitoring and modifying a disease specific drug therapy
• Collecting and reviewing patient history
• Obtaining and reviewing vital signs, including pulse, temperature, blood pressure and respiration
• Ordering, evaluating, and applying the results of laboratory tests directly related to the disease
• Specific drug therapy being managed under an order set, provided such tests do not require the pharmacist to interpret such testing or formulate a diagnosis
• Providing disease or condition specific patient education and counseling

1. Identify and develop a relationship with the collaborative provider.
2. Determine what the scope of the CPA will include such as which diseases/conditions will be the focus and if there are any specific patients or subpopulations to focus on (CPA is patient specific, one per patient).
3. Establish what will be the extent of pharmacist involvement in care (medication reconciliation, ordering labs, refilling prescriptions).
4. Clearly define roles for both the provider and pharmacist. Is there any required training that either side would like to include?
5. Determine a method of communication, include documentation and exchange of patient information, define frequency of communication and define what information will be shared and in what format.
6. Define measurable outcomes to assess the impact and success of the CPA.
7. Inform the patient of the collaboration and impact on their care.

• No direct reimbursement for a CPA. May lead to increased services, such as medication therapy management, that are billable.
• Pharmacists should consider which health outcome metrics they are impacting for patients served through a CPA and determine if an incentive payment can be made from the collaborating provider based on these outcomes.
• Cost-savings for the practice may be realized through the increased collaboration and may be shared with the pharmacist.

• Therapeutic substitution not allowed without the physician’s explicit written consent
• Disease states limited to those specified in protocol or agreement
• Does not include any controlled substances
• Pharmacist can perform a physical assessment
• Pharmacist can order laboratory tests
• Pharmacist can interpret laboratory test results to evaluate but not to be used for diagnosis

• Physician must be nearby the collaborating pharmacist. View the law/regulations for more details here.
• Pharmacist must register with the board and renew annually
• Covers a single pharmacist
• Pharmacist cannot initiate new therapy or discontinue current therapy except as specified in the order set
• Participating primary care provider must be a physician
• Single prescriber
• Each CPA covers one individual patient
• Patient/ drug/disease or condition specific order set prepared by the physician must be based on a face-to-face visit with the patient