Implementation and Successes of an Inpatient Medication Therapy Management Program
Sarah E. White, Pharm.D., BCPS, R.Ph., Deborah L. Sanchez, Pharm.D., BCPS, R.Ph.
Asante Rogue Regional Medical Center, Medford, Oregon
Performing and billing for Medication Therapy Management (MTM) services has traditionally been confined to the outpatient setting. In 2007, our hospital pharmacy department began an inpatient MTM program with the purposes of optimizing patient care and gaining financial reimbursement for cognitive services already provided.
The first step in setting up the inpatient MTM program was to determine the criteria for MTM under state law. In this state, for each consultation the Board of Pharmacy requires a provider order, documentation of the MTM service in the medical record, inclusion of a note written in SOAP (Subjective, Objective, Assessment, Plan) format, and a face-to-face visit with the patient. Next the proper billing codes needed to be determined. Evaluation and Management (E/M) codes were chosen and criteria for Levels 0 through 5 were set. Level 0 means that the MTM is not billable and criteria were not met. Level 1 starts with a low-complexity consult and increases to high complexity with multiple critical issues at Level 5. The higher the level, the higher the dollar amount that is reimbursed. Pharmacists were trained on documentation requirements and the biller was trained on gathering the appropriate data from each note in order to process for billing.
Since implementation the program has grown in many ways. In 2009, 4,236 consults were billed, with an estimate of 8,020 consults in 2014. Billing was $224,000 for 2009 and $1.6 million in net patient service revenue for 2013. Due to the relationship between private insurance predominance and negotiated rates, over time pharmacy revenue has ranged from $12,000 to $55,000 monthly. Pharmacists have expanded their role in patient care and have increased the complexity of medication management that is provided to patients on a daily basis. Pharmacists are more visible to patients and other healthcare professionals. Additionally, the service has provided the framework for adding more pharmacist-managed protocols. Warfarin, vancomycin, aminoglycoside, and renal dosing are now automatic consults that did not exist before the MTM program. The program continues to grow as pharmacists use the MTM structure to pursue additional clinical services.
The inpatient MTM program is a unique and innovative program that has resulted in increased revenue, additional pharmacy clinical services, and greater pharmacist responsibility in patient care.