Utilization of Current Procedural Terminology Codes in Pharmacists' Services Using Medicare Data Claims

OBJECTIVES: Pharmacists are well-suited to provide clinical services including medication therapy management (MTM) to optimize patient outcomes. Legislative support, notably the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) and Centers for Medicare and Medicaid Services (CMS) affirmation, enabled pharmacists to use the Current Procedural Terminology (CPT) codes for documentation and billing of clinical services. Despite legislative support and the potential availability of pharmacists' clinical services, a gap may exist between reported availability and the actual prevalence of these services in real-world settings. The objective of this study was to assess the prevalence of relevant CPT codes in documenting and billing pharmacists’ clinical services using recent available data.

METHODS: This retrospective study utilized the Merative^™ MarketScan^® Medicare database from January 1, 2016, to December 31, 2020. The dataset included deidentified patient information and CPT codes used for billing services. Patients with CPT codes 99605-99607 for face-to-face MTM services, 98966-98968 for telephonic assessment and management (A/M) services, and 99211-99215 for evaluation and management (E/M) services were identified from outpatient claims. Descriptive statistics, including prevalence rates, were calculated using SAS 9.4. This study was approved by the University Institutional Review Board and followed the STROBE guidelines.

RESULTS: A total of 2,784,629 patients were identified between 2016 and 2020. Prevalence rates varied during this period, with lower rates for MTM face-to-face CPT codes (0.06%) and telephonic A/M codes (0.58%), while E/M CPT codes showed higher prevalence rates (87%).

CONCLUSIONS: Study findings exhibited a limited adoption rate for MTM CPT codes in billing pharmacists’ clinical services. Strategies, models, and policies are needed to facilitate and monitor pharmacists’ use of CPT codes and evaluate associated health outcomes. Future research may focus on assessing pharmacists’ perceptions and identifying facilitators and barriers for the use of CPT codes in billing pharmacists’ clinical services.