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Opioid Treatment Program Reimbursement
Description
Opioid Treatment Programs (OTPs) are state and federally regulated to dispense opioid agonist treatment and provide daily supervised dosing of methadone, buprenorphine or naltrexone.
Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) will provide reimbursement for opioid treatment programs as outlined in this policy.
Reimbursement Guidelines
OTP providers may only be reimbursed using the bundled payment codes G1028, G2067 through G2080, and G2215 to G2216.
Only OTP providers are eligible for reimbursement using G0532, G0333, G1028, G2067 through G2080, and G2215 to G2216.
Place of service 58 (non-residential opioid treatment facilities) is required for all claims submitted by OTPs.
Reimbursement for bundled weekly OTP services (G0533, G2067-G2075) is limited to once per 7 days. When multiple drugs are provided to a member in the same week, the G code corresponding to the drug provided for the majority of the week should be filed.
Consistent with FDA labeling, reimbursement for:
- weekly OTP services using G2069 and G2073 is limited to once per 28 days.
- drug take home supply (G2078 and G2079) is limited to three (3) units per 28 days.
When submitting a claim for HCPCS code G0532 (take-home supply of nasal nalmefene hydrochloride, nasal spray) or G2216 (take-home supply of injectable naloxone), OTP providers must note the dosage dispensed to the member in the units field of the claim form (box 24G of the 1500), rounded to the nearest whole number (with a minimum dosage of 1mg).
Rationale
In accordance with CMS, Blue Cross NC will limit reimbursement for OTPs to the codes G0532, G0533, G1028, G2067 through G2080, and G2215 to G2216.
Following SAMHSA guidance, a maximum take-home supply of one month of medication is allowed. Therefore, Blue Cross NC will limit the add-on codes for take home supply of methadone and oral buprenorphine (G2078 and G2079) to be billed 3 times in 28 days (in addition to the weekly bundled payment code).
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com .
| HCPCS Code | Description |
|---|---|
| G0532 | Take-home supply of nasal nalmefene hydrochloride; one carton of two, 2.7 mg per 0.1 ml nasal sprays (provision of the services by a medicare-enrolled opioid treatment program);(list separately in addition to each primary code) |
| G0533 | Medication assisted treatment, buprenorphine (injectable) administered on a weekly basis; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a medicare-enrolled opioid treatment program) |
| G0536 | Peer recovery support services, provided directly or by referral; including leveraging knowledge of the condition or lived experience to provide support, mentorship, or inspiration to meet oud treatment and recovery goals; conducting a person-centered interview to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes; developing and proposing strategies to help meet person-centered treatment goals; assisting the patient in locating or navigating recovery support services; each additional 30 minutes of services (provision of the services by a medicare-enrolled opioid treatment program); (list separately in addition to each primary code) |
| G0560 | Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan: recognizing warning signs of an impending suicidal or substance use-related crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts or risky substance use; utilizing family members, significant others, caregivers, and/or friends to help resolve the crisis; contacting mental health or substance use disorder professionals or agencies; and making the environment safe |
| G1028 | Take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 ml nasal spray (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2067 | Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2068 | Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2069 | Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2073 | Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2074 | Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2075 | Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2076 | Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment by a program physician or a primary care physician, or an authorized health care professional under the supervision of a program physician qualified personnel that includes preparation of a treatment plan that includes the patient's short-term goals and the tasks the patient must perform to complete the short-term goals; the patient's requirements for education, vocational rehabilitation, and employment; and the medical, psycho-social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2077 | Periodic assessment; assessing periodically by qualified personnel to determine the most appropriate combination of services and treatment (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2078 | Take home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2079 | Take home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2080 | Each additional 30 minutes of counseling in a week of medication assisted treatment, (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2215 | Take-home supply of nasal naloxone; 2-pack of 4mg per 0.1 ml nasal spray (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2216 | Take home supply of injectable naloxone (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
Related policy
n/a
References
American Society of Addiction Medicine. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. asam-national-practice-guidelinepocketguide.pdf
Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Federal Guidelines for Opioid Treatment Programs (samhsa.gov): https://store.samhsa.gov/sites/default/files/d7/priv/pep15-fedguideotp.pdf
Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63, Full Document. HHS Publication No. (SMA) 195063FULLDOC. TIP 63: Medications for Opioid Use Disorder | SAMHSA: https://www.samhsa.gov/resource/ebp/tip-63-medications-opioid-use-disorder
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Psychiatry.org - APA Releases Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DS: https://www.psychiatry.org/news-room/news-releases/apa-releases-diagnostic-and-statistical-manual-of
History
11/1/2023 - New policy developed. Medical Director approved. Notification on 11/1/2023 for effective date 1/1/2024. (ss)
12/31/2024 Added codes to Billing and Coding section: G0532, G0533, G0536, G0560. Deleted codes: G2070, G2071, G2072. Updated code definitions throughout. No change to policy intent. (tlc)
Application
These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.
This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.
Disclosures:
Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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