MTM Documentation & Clinical Communication 2 — Questions and Answers
Question 1: Which component of a SOAP note contains the pharmacist's assessment of a drug-related problem identified during an MTM encounter?
- Subjective
- Objective
- Assessment (Correct answer)
- Plan
Correct answer: Assessment
The Assessment section of a SOAP note is where the clinician documents their professional interpretation of findings, including identified drug-related problems.
Question 2: When documenting a Comprehensive Medication Review (CMR), the Personal Medication Record (PMR) must include which of the following for each medication?
- Prescribing physician's DEA number
- Medication name, dose, frequency, and indication (Correct answer)
- Pharmacy acquisition cost
- Patient's insurance copay amount
Correct answer: Medication name, dose, frequency, and indication
CMS requires the PMR to include medication name, strength, dose, frequency, route of administration, and indication for each medication.
Question 3: A pharmacist is documenting a Medication Action Plan (MAP) after a CMR. The MAP is best described as a patient-centered document that:
- Lists all medications with clinical rationale for prescribers
- Provides billing codes for the MTM encounter
- Outlines action steps the patient and care team will take to address medication issues (Correct answer)
- Summarizes the pharmacist's recommendations in clinical terminology
Correct answer: Outlines action steps the patient and care team will take to address medication issues
The MAP is written in patient-friendly language and lists specific action steps for the patient and/or care team to address identified medication-related problems.
Question 4: Under HIPAA regulations, a pharmacist conducting an MTM session by phone must:
- Obtain written authorization before discussing any medication information
- Verify the patient's identity before disclosing protected health information (Correct answer)
- Record the conversation for quality assurance without notification
- Limit discussion to non-controlled substances only
Correct answer: Verify the patient's identity before disclosing protected health information
HIPAA requires verification of patient identity before disclosing PHI in telephone encounters to prevent unauthorized disclosure.
Question 5: Which CMS billing code is used to document a Targeted Medication Review (TMR) with follow-up intervention for Medicare Part D MTM programs?
- 99605
- 99606 (Correct answer)
- 99607
- 99211
Correct answer: 99606
CPT code 99606 is used for MTM services provided by a pharmacist for an established patient, including a TMR with intervention, lasting up to 30 minutes.
Question 6: When a pharmacist sends a written recommendation to a prescriber following an MTM encounter, the communication should include:
- A complete list of all pharmacy dispensing records from the past year
- The specific drug-related problem, proposed intervention, and clinical rationale (Correct answer)
- Patient financial information and insurance coverage details
- The pharmacist's personal opinion on the prescriber's overall prescribing habits
Correct answer: The specific drug-related problem, proposed intervention, and clinical rationale
Effective interprofessional communication to prescribers must clearly identify the drug-related problem, the recommended intervention, and the evidence-based rationale.
Question 7: Documentation of a patient's adherence barriers during an MTM visit is MOST appropriately recorded under which section of a structured MTM note?
- Objective data
- Subjective information (Correct answer)
- Assessment of drug-related problems
- Billing and coding section
Correct answer: Subjective information
Adherence barriers reported by the patient constitute subjective information, as they reflect the patient's self-reported experiences and perceptions.
MTM Documentation & Clinical Communication 2
Which component of a SOAP note contains the pharmacist's assessment of a drug-related problem identified during an MTM encounter?