How do pharmacists bill MTM codes 99605 to 99607?

MTM billing runs on three tracks that rarely meet. Medicaid and commercial plans pay 99605, 99606 and 99607 on a professional claim with the pharmacist as rendering provider. Part D plans pay comprehensive medication reviews through their own vendor platforms, not through a CPT claim. Medicare Part B does not pay the codes at all.

What do CPT 99605, 99606 and 99607 cover?

They are time-based codes for medication therapy management provided by a pharmacist, individually and face to face with the patient. 99605 is the first 15 minutes with a new patient, 99606 is the first 15 minutes with an established patient, and 99607 is each additional 15 minutes, reported only alongside one of the other two.

CPT describes MTM as assessment and intervention by a pharmacist, on request, built on a review of the patient’s history and complete medication profile, prescription and nonprescription, with recommendations to improve outcomes and adherence. Three words in the descriptor carry most of the billing weight: pharmacist, individual and face to face. A technician’s prep time, a group class and a chart review done without the patient are not billable under these codes.

CPT 99605 vs 99606: who counts as a new patient?

Payers, not CPT, set the lookback that makes a patient new for MTM. Minnesota and Michigan both allow one 99605 per provider per member per 365 days, and every later visit in that window is 99606. A pharmacy that bills 99605 to a patient it already saw inside the payer’s window gets a denial or a downcode. In our audit of 1,860 pharmacist MTM claims, 99605 was billed for an already-seen patient on 11% of new-patient MTM claims.

How CPT 99607 works as an add-on

99607 never stands alone. It goes on its own claim line under 99605 or 99606, one unit for each additional 15 minutes. Some payers pay it separately and some do not: TennCare treats 99607 as informational and pays a case rate on the base code, so the add-on documents time without changing payment.

Does Medicare pay pharmacists for 99605?

No. 99605 to 99607 carry a status indicator of X on the Medicare Physician Fee Schedule, a statutory exclusion, because pharmacists are not among the practitioners who can bill Part B directly. A pharmacy that sends these codes to a Medicare Administrative Contractor gets a denial, not a payment.

Medicare pays for pharmacist work through two other routes. Inside a physician practice, a pharmacist is auxiliary personnel under 42 CFR 410.26, and the visit bills incident to the supervising physician or nonphysician practitioner under that practitioner’s NPI. CMS has stated that 99211 is the only office visit level available for a pharmacist’s incident-to service. Since January 1, 2026, direct supervision for incident-to services can be met through real-time audio and video, though not audio alone. Pharmacist time can also count as clinical staff time on care management codes when the pharmacist works under the billing practitioner’s supervision, which we cover in our guide to billing CCM and RPM together.

The second route is Part D, and it does not use a CPT claim at all.

How do Part D plans pay for comprehensive medication reviews?

Every Part D sponsor must run an MTM program under 42 CFR 423.153(d), and it pays pharmacists through its own contracts or an MTM vendor, not through 99605 claims. The pharmacist documents the encounter in the sponsor’s or vendor’s platform, and payment follows that platform’s rate schedule.

• Comprehensive medication review (CMR): offered at least once a year, interactive, in person or by synchronous telehealth, with a written summary in the CMS Standardized Format.
• Targeted medication review (TMR): at least quarterly, with follow-up interventions when a problem turns up.
• Who qualifies: sponsors can require at most three chronic diseases and must include all ten core diseases, with HIV/AIDS added for 2025. They can require at most eight Part D drugs and must count all maintenance drugs.
• Cost threshold: $1,276 in annual drug cost for 2026, rising to $1,340 for 2027.

The money lost here is rarely a denial. It is a completed review that never reached the platform. Across 19 pharmacy billing reviews, 14% of completed Part D CMRs were never documented in the plan’s MTM vendor platform, so they were never paid.

Which Medicaid programs pay MTM codes, and how much?

Medicaid is where 99605 to 99607 earn most of their money, and every state writes its own rules. Minnesota pays $52, $34 and $24 for 99605, 99606 and 99607. Montana pays $58.45, $39.75 and $16.04. Utah pays $53.48, $32.94 and $16.68.

Limits matter as much as rates:

• Minnesota: one 99605 per provider per member per 365 days, a maximum of seven 99606 per member per 365 days, and a maximum of four 99607 units per date of service, with prior authorization above that. The pharmacist enrolls individually and bills on an 837P as rendering provider. Medicare-eligible members and nursing facility residents are excluded.
• Utah: one initial and three follow-up visits per calendar year, for members who are not Part D eligible and take at least three medications for at least one chronic disease.
• Maryland: since January 1, 2024, one 99605 or 99606 per 365 days and two units of 99607, after a program referral, for members with three or more chronic diseases or ten or more maintenance drugs.
• Michigan: an 837P with the pharmacist’s individual Type 1 NPI as rendering provider and the pharmacy, FQHC, tribal health center or rural health clinic as billing provider.
• Missouri, Mississippi and Tennessee: Missouri caps MTM at four units per rolling month per provider, Mississippi pays MTM only inside its Elderly and Disabled Waiver with modifier U1, and Tennessee pays case rates of $55 and $75 through modifiers U1 to U3.

How do you build a clean MTM claim, step by step?

1. Pick the track. Check whether the member is Medicare or Part D eligible before the visit. Most Medicaid MTM programs exclude them, which sends the review to the Part D sponsor’s program instead.
2. Enroll the pharmacist. The pharmacist needs an individual NPI, enrollment with each Medicaid program and credentialing with each commercial plan before the first claim. Our credentialing team tracks those applications through to approval.
3. Match the taxonomy. Use 183500000X for Pharmacist or a specialty the payer recognizes, such as 1835P1200X Pharmacotherapy, 1835P2201X Ambulatory Care or 1835P0018X Pharmacist Clinician, and keep it identical to the payer’s enrollment record.
4. Build the 837P. The pharmacist’s Type 1 NPI goes in the rendering field and the pharmacy’s or clinic’s Type 2 NPI in the billing field. Place of service is 01 for a pharmacy, 11 for an office, 12 for the patient’s home, and 02 or 10 for telehealth where the state allows it.
5. Code the time. Bill the base code for the first 15 minutes and 99607 for the rest, with total face-to-face minutes written in the note.
6. Check frequency before you submit. Compare the visit against the payer’s annual and per-day limits, because an over-limit line denies however well it is documented.

Dispensing claims work differently. NCPDP Professional Pharmacy Service fields, such as code MR for medication review, record a drug utilization intervention on the dispensing claim. Every Medicaid program we found bills 99605 to 99607 on the professional claim instead.

How many units of 99607 can you bill?

Count total face-to-face minutes, take away the first 15 covered by the base code, then apply the payer’s unit rule. CPT’s general time convention reaches a unit once the midpoint passes, which makes 8 minutes past a full block the trigger. Maryland follows that, defining a unit as 8 to 15 minutes. Highmark’s commercial levels start the second level at 16 minutes.

In Minnesota a new-patient visit pays $52 for 99605 alone, $76 with one 99607 unit, $100 with two, $124 with three and $148 with four, the per-day maximum.

Time documentation decides whether those add-on units hold up. 99607 was billed without a documented total session time on 23% of the MTM claims we audited, which turns every add-on unit into a recoupment risk on review. Our medical coding team checks minutes against units before the claim goes out.

What does MTM earn a pharmacy billing Minnesota Medicaid?

Take an independent pharmacy with one MTM pharmacist seeing Minnesota Medicaid members. Each month it runs 20 new-patient visits of 40 minutes and 30 follow-ups of 20 minutes.

• New-patient visits: 40 minutes is the first 15 plus 25 more. That is one full 99607 unit and 10 minutes past the next block, which passes the midpoint, so two units. 99605 at $52 plus two units at $24 is $100 a visit, or $2,000 a month.
• Follow-ups: 20 minutes is the first 15 plus 5, which does not reach the midpoint, so 99606 alone at $34. Thirty visits is $1,020 a month.
• Documented value: $3,020 a month, or $36,240 a year.

Now apply what we see in pharmacy billing reviews, where 18% of documented pharmacist clinical services were never billed. That is $543.60 a month that never becomes a claim. Of the $2,476.40 billed, a 14.2% first-pass denial rate, the average our client practices carried at onboarding, puts $351.65 in denials. If 19% of denied claims are never reworked or appealed, $66.81 of that is simply abandoned.

Together that is $610.41 a month, or about $7,325 a year, roughly a fifth of the documented value of the program. The error in the other direction is just as costly. A biller who rounds each 40 minute visit to 45 and bills three 99607 units claims $124 instead of $100, which is $480 a month of overpayment the plan can recoup later.

Why do pharmacist MTM claims deny?

Most MTM denials trace back to who rendered the service, not what was coded. Across 1,860 pharmacist MTM claims in our audit, rendering NPI or enrollment problems caused 34% of denied MTM claims, member eligibility caused 25%, frequency limits 22%, and time and 99607 unit errors 19%.

The most common MTM billing mistakes

• Sending 99605 to 99607 to Medicare Part B, where the codes are a statutory exclusion.
• Billing a Part D CMR as a CPT claim instead of documenting it in the sponsor’s MTM platform.
• Putting the pharmacy’s Type 2 NPI in the rendering field, or billing before the pharmacist’s own enrollment is approved.
• Billing Medicaid MTM for a dual-eligible member whom the state excludes.
• Repeating 99605 inside the payer’s new-patient window.
• Billing 99607 units without total minutes in the note, or rounding time up past the payer’s rule.
• Submitting 99607 alone or on the same line as the base code.

When these do get through, appeals still pay: ours were overturned 68% of the time. A denials and AR recovery queue that reads MTM denials by cause gets the eligibility and frequency fixes back to the front desk.

Should a pharmacy bill MTM in house or outsource it?

MTM is a small line on most pharmacy ledgers, which is exactly why it goes unworked. The pharmacist documents the visit, nobody owns the medical claim, and the denial ages out. Across the practices in our billing reviews, fully loaded in-house billing cost 7.9% of collections for practices under $2M, against 3% to 6% of collections for an outsourced partner. In our 2026 survey, 42% of practice managers said nobody owns denial follow-up full time, and MTM is usually the first queue to lose an owner.

Keep it in house if one person already owns pharmacy medical claims, checks enrollment before the first visit, and reconciles Part D platform payments monthly. Outsource it when MTM sits with whoever has time between fills. Our pharmacy billing services cover Part B drugs, vaccines and pharmacist visits alongside MTM, our pharmacy revenue cycle management page covers the front end from benefit investigation onward, and full-service medical billing runs inside the pharmacy system you already use. To see what your own MTM claims are leaving behind, start with a free billing review.

MTM billing routes compared: which payer pays, and on what claim?

The payer decides the code, the claim and who can be the rendering provider.

Independent community pharmacies

The pharmacy is both billing provider and place of service 01, and the pharmacist is rendering provider on every MTM claim. The problem is volume: MTM is a few claims a week beside hundreds of dispensing claims, so nobody watches the 837P side. Enrollment is the gate. Medicaid will not pay a 99605 from a pharmacist whose individual enrollment is still pending, and credentialing lapses delayed payment for 1 in 12 providers added in the prior year across our reviews. Start the pharmacist’s enrollment before the first MTM appointment is booked. Those dispensing claims carry their own exposure, set out in our guide to PBM audit triggers and the records to keep.

Primary care and internal medicine clinics

An embedded pharmacist creates a choice. Medicare patients go incident-to under the supervising practitioner at 99211, or the pharmacist’s time counts toward the clinic’s care management codes. Medicaid and commercial patients can go on 99605 to 99607 with the pharmacist as rendering provider and the clinic as billing provider. Decide the route per payer in the scheduling template, not at charge entry. Our primary care billing page covers the wider care management code set.

FQHCs and rural health clinics

Michigan Medicaid names FQHCs, tribal health centers and rural health clinics as billing providers for pharmacist MTM, with the pharmacist’s individual NPI as rendering. Medicare pays these centers through their own encounter rules, and a pharmacist is not one of the practitioners who generates a Medicare encounter, so MTM value at a center comes from Medicaid and from care management time. Check whether your state pays MTM inside or outside the encounter rate before booking it. See FQHC billing.

Behavioral health and psychiatric pharmacists

Psychiatric pharmacists use taxonomy 1835P1300X, and many state Medicaid programs route mental health benefits to a carve-out plan, so the MTM claim may belong to a different payer than the medical visit. Check which plan holds the member’s behavioral health benefit before billing. Commercial networks move slowly here: new clinicians waited a median 96 days to go in-network with commercial payers in our reviews. See psychiatry billing.

Long-term care and skilled nursing

Minnesota excludes nursing facility residents from its Medicaid MTM benefit, and other states follow similar rules. The consultant pharmacist’s monthly drug regimen review is a facility obligation paid by the facility, not a 99605 claim. A resident enrolled in Part D can still be targeted by the plan’s MTM program, so the CMR runs through the sponsor’s platform like any other.