Learn CPT 99605 billing for Medication Therapy Management, including eligibility, documentation, reimbursement, and billing errors to avoid.
Medication Therapy Management (MTM) is one of the most clinically valuable - yet frequently misunderstood - services in pharmacy practice. When billed correctly, CPT 99605 allows pharmacists to be reimbursed for face-to-face patient consultations that directly improve medication adherence, reduce adverse drug events, and optimize therapeutic outcomes. This guide breaks down everything providers need to know about billing CPT 99605 accurately and compliantly.
What Is CPT 99605?
CPT 99605 is a pharmacist-specific billing code used to report Medication Therapy Management services provided during an initial, face-to-face encounter with a new patient, lasting up to 15 minutes. MTM involves a comprehensive review of a patient's complete medication profile - including prescriptions, over-the-counter drugs, herbal supplements, and vitamins - to identify drug therapy problems and optimize treatment outcomes.
Per CMS guidelines, MTM services were introduced through the Medicare Modernization Act of 2003, requiring all eligible Medicare Part D beneficiaries to have access to these services.
The MTM CPT Code Family: 99605, 99606, and 99607
Three codes make up the MTM billing set:
- CPT 99605 – Initial 15-minute face-to-face MTM encounter with a new patient
- CPT 99606 – Follow-up 15-minute encounter with an established patient
- CPT 99607 – Add-on code for each additional 15-minute increment (used with 99605 or 99606)
Example: A pharmacist spends 45 minutes with a new patient for an initial MTM session. The correct billing would be: 99605 (first 15 minutes) + 99607 × 2 (two additional 15-minute increments).
Note that CPT 99607 cannot be billed independently - it must always be paired with either 99605 or 99606. These codes are also not intended for routine dispensing activities, product information handouts, or standard point-of-sale counseling.
Who Can Bill CPT 99605?
CPT 99605 is designated specifically for licensed pharmacists and pharmacy interns under direct pharmacist supervision. Physicians and other qualified healthcare providers may also provide MTM services, but these pharmacist-specific codes are most commonly used in community pharmacy, ambulatory care, and clinical pharmacy settings.
For practices that also offer coordinated care programs - such as Chronic Care Management (CCM) or Transitional Care Management (TCM) - understanding how MTM integrates with broader care workflows is essential. Learn more about how medication reconciliation supports CCM and transitional care outcomes.
Patient Eligibility Criteria
Not every patient qualifies for MTM services. According to the Medicare Part D MTM program requirements, a patient must generally meet the following criteria:
- Multiple chronic conditions (typically two or more), such as diabetes, hypertension, heart failure, dyslipidemia, or asthma
- Multiple Part D covered drugs (commonly five or more medications)
- Risk of medication-related problems due to complex regimens, polypharmacy, or multiple prescribers
- Likelihood of incurring high Part D drug costs (the annual threshold is updated by CMS each plan year)
Medicaid programs may also cover MTM using CPT 99605, though eligibility and reimbursement rules vary by state. Providers should always confirm payer-specific criteria before rendering services.
Five Core Elements of MTM Documentation
For a claim under CPT 99605 to be compliant, documentation must reflect the five core MTM service elements:
- Medication Therapy Review (MTR) – A face-to-face (or telehealth) comprehensive review of all medications, including nonprescription and herbal products
- Personal Medication Record (PMR) – A documented list of all medications, dosing instructions, prescribed indications, allergies, and prescriber details
- Medication-Related Action Plan (MAP) – A patient-friendly care plan summarizing identified drug therapy problems and recommended follow-up actions
- Intervention and/or Referral – Communication with the prescribing provider when medication changes or clinical follow-up is needed
- Documentation and Follow-Up – A record of the encounter, patient education provided, and scheduled monitoring or follow-up contacts
Incomplete documentation is among the leading causes of MTM claim denials. Every element must be present in the patient record to support the billed service.
Reimbursement Rates for CPT 99605
Reimbursement for CPT 99605 varies by payer, geographic location, and contract terms. General benchmarks under Medicare and state Medicaid programs include:
Commercial payers are not required to cover MTM under CPT codes, and many do not. Providers should always verify coverage and pre-authorization requirements before scheduling a session. Patients whose insurance does not cover MTM may be billed directly; however, providers must apply consistent fee structures and not discount or waive fees for Medicare patients.
Common Billing Errors to Avoid
- Billing 99607 without 99605 or 99606 – The add-on code is never standalone
- Using 99605 for an established patient – Follow-up visits with existing MTM patients require 99606
- Billing for routine dispensing counseling – MTM codes apply only to structured, comprehensive reviews, not standard product education at the point of sale
- Exceeding frequency limits – Most payers cap 99605 at one session per patient per year and 99606 at five or fewer sessions annually
- Missing ICD-10 linkage – At least one diagnosis code on the claim must reflect a qualifying chronic condition
For practices managing complex post-discharge patients, it is also worth understanding how medication reconciliation overlaps with Transitional Care Management billing - particularly when patients are recently discharged and at high risk for medication-related complications.
Telehealth Considerations for MTM
MTM services may be delivered via telehealth in many states and under certain payer agreements. During and after the COVID-19 public health emergency, CMS expanded telehealth flexibilities that allowed pharmacists to conduct MTM sessions virtually. While some provisions have since been modified, many state Medicaid programs and Medicare Advantage plans continue to reimburse telehealth-delivered MTM under CPT 99605 and 99606.
The HHS Telehealth Resource Center notes that MTM may also be billed concurrently with remote patient monitoring (RPM) services, provided that time and effort are not counted twice across codes.
Integrating MTM into a Broader Care Management Strategy
MTM does not exist in isolation. For pharmacists and care teams managing patients with complex, chronic conditions, CPT 99605 is most effective when embedded within a broader care coordination strategy. Practices offering remote patient monitoring alongside CCM and TCM services are better positioned to capture the full clinical and financial value of medication management interventions.
By accurately billing CPT 99605 and supporting codes, pharmacists not only secure appropriate reimbursement - they demonstrate the measurable value they bring to the patient care team.
Conclusion
CPT 99605 plays a critical role in helping pharmacists deliver and document high-value Medication Therapy Management services for patients with complex medication needs. When billed correctly, MTM not only improves medication adherence, reduces adverse drug events, and enhances clinical outcomes, but also creates a sustainable reimbursement opportunity for pharmacy practices.
Understanding patient eligibility, documentation requirements, coding rules, and payer-specific guidelines is essential to avoiding denials and maintaining compliance. As healthcare continues to shift toward coordinated, value-based care, pharmacists who effectively integrate CPT 99605 into broader care management programs will be better positioned to demonstrate both clinical and financial impact.
Frequently Asked Questions
Q1. Can CPT 99605 be billed by a physician, or is it exclusive to pharmacists?
CPT 99605 is primarily designed for licensed pharmacists providing Medication Therapy Management services. Physicians usually bill medication management under E/M codes instead. Pharmacy interns may assist only under direct pharmacist supervision, with the supervising pharmacist’s NPI used on the claim.
Q2. How often can CPT 99605 be billed for the same patient?
CPT 99605 is generally billed once per patient per provider each year because it applies to new patient MTM visits. Follow-up sessions are billed using CPT 99606. Payer frequency limits may vary, so eligibility should always be verified beforehand.
Q3. Is a face-to-face encounter required to bill CPT 99605, or can it be done via phone?
CPT 99605 traditionally requires a face-to-face encounter. Many payers now allow telehealth video visits for MTM services, but telephone-only consultations are often not accepted. Always confirm telehealth policies with the payer before billing.
Q4. What ICD-10 codes should be linked to a CPT 99605 claim?
Claims should include ICD-10 codes for qualifying chronic conditions such as diabetes, hypertension, heart failure, COPD, or dyslipidemia. The diagnosis must support the medical necessity of the MTM service and be documented in the patient record.
Q5. Can CPT 99605 and CPT 99606 be billed on the same date of service?
No, CPT 99605 and 99606 cannot be billed together on the same date. CPT 99605 is used for initial MTM visits, while 99606 applies to follow-up visits. Additional time beyond 15 minutes is reported using CPT 99607.
Q6. Does Medicare Part B cover CPT 99605, or is it only a Part D benefit?
CPT 99605 is mainly covered under Medicare Part D MTM programs, not Medicare Part B. Pharmacists generally cannot bill Part B directly unless services qualify under incident-to billing in physician-led practices. Coverage rules differ across payers and states.
Q7. What happens if MTM documentation is incomplete at the time of audit?
Incomplete documentation can lead to claim denials, payment recoupments, or compliance reviews. Required MTM elements such as the medication review, care plan, and follow-up details must be properly documented. In MTM billing, undocumented services are considered not performed.