MTM VS Disease State Management

[DIJ]

Hey everyone. I'm a pharmacy student, having a little trouble understanding the differences between MTM and disease state management at the retail level. I've heard these terms used interchangeably, but as I understand it, disease state management is a separate service from MTM. A medication related action plan is listed as one of the five core elements of an MTM service, but it seems that it is very basic. In other words, it seems like it's use is intended for the patient to track their own progress. So, my question, are there any retail chains offering disease state management services? I would like to get a hold of one and ask some questions. I need to know the details of their service, how they integrate it into their workflow, who pays them and at what amount, what training/certification is required to receive reimbursement, etc. If anyone could point me in the right direction, I'd really appreciate it.

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[DIJ]

If nobody knows any retailers, does anybody know if I'm right? Is disease state management the same thing as MTM?

 

[bacillus1]

I would say MTM is a subset of disease state management. MTM describes a particular model, with the reimbursement as a part of this model. The term MTM really is to describe a particular service so it can be billed. Disease state management is too vague of a term to use in billing.

That's my understanding. Never seen an MTM session in practice.

 

[spacecowgirl]

What I do is very much like disease state management vs. MTM. I do adjustments in the visit because I have collaborative practice agreements. I do not bill right now, hoping it will be a moot point soon, long story. Anyway, my services are more focused on the condition for which the person was referred, but of course I look at every med and make recommendations for changes that fall outside my scope of my CPAs. I have never provided MTM in a retail setting.

 

[DIJ]

So if you were to bill for your services which focus more on the condition, like say diabetes management, would you use the same MTM CPT codes and be reimbursed as though you provided MTM?

 

[spacecowgirl]

So if you were to bill for your services which focus more on the condition, like say diabetes management, would you use the same MTM CPT codes and be reimbursed as though you provided MTM?

Yes. Because I do all the things that are required for an MTM visit according to the payers.

 

[Jenloga]

I've done "MTM" as a P2-P3 summer intern with Walgreens which was pretty much "medication reconciliation." It involved me looking in the computer at the person's drug list, chatting casually about all the drugs and verifying the patient knows what they're for and how they are dosed. I asked whether any OTC/supplements/etc. were taken. I asked about how frequently the doctor is seen, if BP is taken at home, etc etc... I looked for interactions using the Walgreens computer system and did a Lexi-Interact check with their OTCs. I advised them anything I could think of regarding any of their medications or any lifestyle changes.

There was a particular insurance plan in that state that covered MTM services so I documented the intervention on a form and faxed it in for reimbursement. Other things covered on that plan were therapy/dose changes, calls to the prescriber to verify doses/drugs/etc... it was a nice idea but very time consuming and a pain to fax in forms for reimbursement (a lot of resistance by pharmacists, hence having their intern do it), I'm not sure the plan is still reimbursing for that now since there was a low volume of claims during their "trial period".

 

[spacecowgirl]

Not every payer that pays for "MTM" reimburses the MTM codes either. For example Humana (who uses Outcomes) https://www.getoutcomes.com/userdocs/White_Page_Humana.pdf

 

[bananaface]

Disease state management focuses on both drug and non drug strategies for a particular condition. MTM is medication regimen focused and ideally encompasses all disease states and medications for a patient.

Both are narrower and broader in scope than the other, in different ways.