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Medication Therapy Management (MTM) Guidance

Looking to complete MTM services? Find the guidance you need here.

Written by Taher Rehmanji

Table of Contents:

  1. Identifying Eligible Patients for MTM

  2. Using MedMe to complete MTMs

  3. Billing MTM Claims in MedMe

  4. To submit the claim within MedMe

  5. Best Practices

  6. Next Steps

Identifying Eligible Patients for MTM

MTM (Medication Therapy Management) allows pharmacists to provide comprehensive medication reviews and optimize therapeutic outcomes for patients with complex medication needs.

MTM Eligibility Criteria

California Eligibility Criteria

To qualify for Medication Therapy Management (MTM) under Medi-Cal, patients must meet all of the following requirements:

General Requirements:

  • Must be an outpatient (not admitted to hospital or a long-term care/institutional setting)

  • Must not be eligible for Medicare Part D

  • Must agree to participate and may opt out at any time

Medication & Condition Requirements

Patients must meet either set A or B of the following combinations:

Set A:

  • A. Outpatient

  • B. Not eligible for Medicare Part D

  • C. Currently prescribed and taking a qualified specialty drug within one of these covered disease categories:

    • Diabetes

    • Asthma or Chronic Obstructive Pulmonary Disease (COPD)

    • Hypertension

    • Cardiovascular disease

    • Severe mental health disorders

    • HIV/AIDS

    • Hepatitis C (HCV)

    • Cancer

    • Blood factors or Hemlibra for bleeding disorders

    • Dyslipidemia

    • Bone diseases such as Osteoporosis or Osteoarthritis

    • Alzheimer’s disease

    • End-Stage Renal Disease (ESRD)

    • Cystic Fibrosis

    • Multiple Sclerosis

    • Autoimmune disorders (e.g., Rheumatoid Arthritis)

  • D. Taking five or more chronic medications (includes prescriptions, non-prescription products, herbal remedies, or dietary supplements)

  • F. Meets at least one risk-of-treatment-failure criterion (see below)

  • G. Agrees to participate

Set B:

  • A. Outpatient

  • B. Not eligible for Medicare Part D

  • C. Currently prescribed and taking a qualified specialty drug within one of the disease categories listed above

  • E. Taking a single medication whose Medi-Cal reimbursement exceeds $75,000 per year

  • F. Same risk-of-treatment-failure and participation requirements as above (F + G)

Risk-of-Treatment-Failure Criteria (F)

Patients must meet at least one of the following:

  • Receiving care from more than one prescriber

  • Abnormal lab values that may be affected by medication therapy

  • Non-adherence (underuse or overuse) to medication for more than 3 months

  • Limited health literacy or socio-cultural barriers that affect adherence

  • Recently experienced an adverse event (medication or otherwise)

  • Taking high-risk medications, including narrow therapeutic index drugs (e.g., warfarin, phenytoin, methotrexate, digoxin)

  • Recent hospitalization or SNF discharge within 14 days with a new medication regimen

  • Referred for MTM by another healthcare provider

Michigan Eligibility Criteria

To qualify for Medication Therapy Management (MTM) under Michigan Medicaid, a beneficiary must meet all of the following:

  1. Be enrolled in Michigan Medicaid

    • This includes beneficiaries in Fee-for-Service (FFS) or Medicaid Health Plans.

    • The beneficiary must not be covered under Medicare Part D (since Medicare Part D plans already provide their own MTM programs).

  2. Have at least one qualifying chronic condition from the approved list below:

    • Alcohol Use Disorder

    • Alzheimer’s Disease and Related Disorders or Senile Dementia

    • Anemia (Including Sickle Cell Anemia)

    • Atrial Fibrillation

    • Asthma

    • Bipolar Disorder

    • Cancer (All Inclusive)

    • Cataract

    • Chronic Kidney Disease

    • Chronic Obstructive Pulmonary Disease (COPD) & Bronchiectasis

    • Cystic Fibrosis

    • Deep Venous Thrombosis (while on anticoagulation) / Pulmonary Embolism (chronic anticoagulation)

    • Depression

    • Diabetes Mellitus

    • Glaucoma

    • Heart Failure

    • Hemophilia

    • HIV

    • Hypertension

    • Ischemic Heart Disease

    • Lead Exposure

    • Liver Disease, Cirrhosis, and Other Liver Conditions

    • Obesity

    • Osteoporosis

    • Rheumatoid Arthritis / Osteoarthritis

    • Schizophrenia, Schizotypal, Delusional, and Other Non-Mood Psychotic Disorders

    • Stroke / Transient Ischemic Attack

    • Substance Use Disorder

    • Tobacco Use Disorder

    • Viral Hepatitis

  3. Be prescribed at least one medication used to treat or prevent one of the above chronic conditions.

    • This ensures that MTM services are targeted to beneficiaries where medication use plays a key role in management or prevention.

Pharmacies should create systems to easily identify patients who may qualify—such as:

  • Filtering patient profiles in the PMS for those on chronic disease medications or high-cost therapies.

  • Training pharmacy technicians to flag potential candidates during prescription drop-off or refill interactions.

Once a potential candidate is identified, the pharmacist should:

  1. Invite the patient to a private discussion area — to ensure confidentiality and encourage open communication about medications, side effects, and adherence challenges.

  2. Obtain informed consent for the MTM service, explaining that the goal is to improve safety, reduce costs, and ensure optimal outcomes. A patient can opt-out at anytime

  3. Book a follow-up MTM session while the patient is still present. This dramatically improves continuity of care and helps ensure follow-up appointments aren’t missed.

Tip: Pharmacies that proactively schedule MTM follow-ups see significantly higher completion and reimbursement rates.

Using MedMe to complete MTMs

Pharmacists should complete the MTM questionnaire linked to the appointment type within MedMe.

Step 1: Select the appointment from the calendar or dashboard

Step 2: Select Edit Documentation


​

Step 3: Complete the Relevant Questionnaires

This ensures all required documentation is collected in a standardized and billable format.

Key items to complete include:

  • Patient consent and MTM eligibility criteria

  • Indication for assessment

  • Medication list, allergies, and medical history

  • Drug therapy problems, interventions, and care plan notes

If a field is marked as if applicable it means that it only needs to be collected if it is pertinent to the encounter.

Optional but highly recommended tools:

  • AI Scribe: Automatically document patient discussions while you focus on care. This removes the need to type and finish documentation after the patient has left.

  • Import Data: Upload a screenshot from your PMS to pre-populate the medication list before the visit begins, saving valuable time.

Please Note: Always ensure the documentation meets your state’s requirements — if it wasn’t documented, it didn’t happen.

Billing MTM Claims in MedMe

Billing MTM services through MedMe is simple and streamlined.
Pharmacies can submit medical claims (CMS-1500 or 837P) directly for the following CPT codes:

CPT Code

Description

When to Use

99605

Initial 15-minute MTM with new patient

Use for a patient’s first-ever MTM at your pharmacy

99606

Initial 15-minute MTM with established patient

Use for any subsequent MTM visits for an established patient

99607

Each additional 15-minute increment

Add this for sessions longer than 15 minutes

Examples of Billing Calculations

  • John Smith: First MTM (30 min) → 99605 + 99607 (1 unit)

  • Gena Ross: Second MTM (15 min) → 99606

  • Ashley Pilot: Third MTM (45 min) → 99606 + 99607 (2 units)

State Examples

State

Allowed MTM Frequency

99605 (Initial)

99606 (Established)

California (Medi-Cal)

6 sessions per 365-day period (1 initial + 5 follow-ups)

1 per patient per year

Up to 5 per patient per year

Michigan (Medicaid)

8 sessions per 365-day period (1 initial + 7 follow-ups)

1 per patient per year

Up to 7 per patient per year

Reminder: MTM must be billed as a medical claim, not a pharmacy claim.
Claims exceeding state limits require additional medical justification.

To submit the claim within MedMe:

Step 1. Select Edit Documentation & Complete Relevant Questionnaires

Step 2. Select Claims Questionnaire

Step 3. Enter CPT Codes

Reminder: 99607 must only be submitted in combination with 99605 or 99606

Step 4. Enter ICD Codes

Tip: You can start typing to search for a particular ICD code. MedMe has populated a list of the most common ICD codes selected. If the codes in the list don't match you can select "Other" to enter your own.

Accurate ICD coding is essential for a successful claim. It identifies the medical conditions that qualify the patient for the MTM service and documents the conditions that were assessed or managed during the encounter.

Step 5. Add Rendering Provider Name and NPI

Step 6. Submit the Claim When Ready

Select this checkbox for when you're ready for MedMe to process the claim.

Tip: If a claim is not ready for submission yet, mark the appointment as ARRIVED and filter for it when you're ready to complete it on the Appointments Tab

Step 7. View Claims Within Your Claims Dashboard

Best Practices

  • Always record start/end time, reason for visit, assessment, and plan in your MedMe chart.

  • Bill 99607 only in combination with 99605 or 99606.

Next Steps

  • Review MTM eligibility details from your official state Medicaid agency

  • Train staff on patient identification workflows.

  • Enable AI Scribe and Import Data features for efficiency.

  • Start billing MTM with MedMe today!

For further help, reach out to the MedMe support team

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