Coding and Billing for OTP Services
Table of Contents
- Coding and Billing for OTP Services
- Coding for OTP Weekly Bundles
- Separate Add-on Codes
- Frequency of Use and Billing
- Billing Cycles
Coding and Billing for OTP Services
CMS designated specific HCPCS G-codes (G2067 through G2080, G2215, G2216 and G1028) for weekly bundled opioid treatment services on Medicare Part B professional and institutional claims. Only OTPs can bill Medicare using these specific codes for OTP services.
- Providers not enrolled as OTP can bill HCPCS codes G2086 through G2088 for an episode of OUD treatment offered by physicians and other practitioners in the office setting.
- Use the Physician Fee Schedule for pricing of G2086 through G2088.
Please note: The guidance below applies to only OTP enrolled providers.
Coding for OTP Weekly Bundles
HCPCS codes G2067 through G2075 describe the weekly bundled services provided to Medicare beneficiaries and are defined as seven continuous days of services.
These weekly bundle HCPCS codes include MAT administration and dispensing, patient intake activities, substance use disorder counseling and individual/group therapy, drug testing and/or periodic patient assessments.
The threshold for billing the codes describing weekly episodes (HCPCS codes G2067-G2075) is the delivery of at least one service in the weekly bundle.
Each bundled HCPCS code describes the specific medication and route of medication, given to your Medicare patient. Please ensure you are coding your claims with the correct HCPCS code based on this detail.
- Methadone (G2067)
- Buprenorphine oral (G2068)
- Buprenorphine injectable (G2069)
- Buprenorphine implants (insertion, removal, and insertion/removal) (G2070, G2071, and G2072)
- Extended-release, injectable naltrexone (G2073)
- Non-drug bundle (G2074)
- Medication not otherwise specified (G2075)
New for 2024 HCPCS Code G0137
G0137 is defined as intensive outpatient services. OTPs may bill G0137 one time per week if a minimum of nine services are provided to the patient during a continuous seven days. Here is a list of those services:
- Individual and group therapy and therapeutic activities
- Family counseling
- Occupational therapy
- Patient training and education closely related to the condition the patient is being treated for
- Drugs and biologicals used for therapeutic purposes
- Excludes opioid agonist and antagonist used in emergency, expected overdose, situations
- Diagnostic testing
- Excludes toxicology tests
Separate Add-on Codes
CMS established G-codes to identify add-on services. The following codes are used in addition to the weekly bundle services, when applicable:
- Intake activities (G2076)
- Periodic assessments (G2077)
- Take-home supplies of methadone (G2078) and take home supplies of oral buprenorphine (G2079)
- Can be reported without the weekly bundle code
- Additional counseling furnished (G2080)
- Take-home supply of nasal naloxone (G2215)
- Take-home supply of injectable naloxone (G2216)
- Take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 ml. nasal spray (G1028)
Frequency of Use and Billing
The following rules apply to OTP billing and payment; this will help to ensure claims are billed properly and paid on first submission:
- You should not bill for the same beneficiary more than once per seven-day period, except in limited situations such as a beneficiary starting treatment at the OTP in the middle of the OTP’s standard weekly billing cycle
- You will report a single date of service in the “From” and “To” fields of the claim
- Some of the bundled payment codes describe a drug typically only administered once per month, such as the injectable drugs, or once in a six-month period, in the case of the buprenorphine implants
- Do not use HCPCS codes G2069 and G2073 more than once every four weeks
- Do not use HCPCS codes G2070 and G2072 more than once every six months
- Do not use HCPCS code G1028 more than one time per month
- You may give Medicare beneficiaries OUD services at more than one OTP within a seven-day period in certain, limited clinical situations, such as guest dosing or when a beneficiary transfers care between OTPs. Each of the involved OTPs may bill the appropriate HCPCS codes for the services given to the beneficiary, but both OTPs must maintain enough medical record documentation to reflect the clinical situation and services supplied
- Instances in which a beneficiary switches from one drug to another, the OTP should only bill for one code describing a weekly bundled payment for that week. Determine which code to bill based on which drug you gave the beneficiary for most of the week
- Bill the add-on code HCPCS code G2076 describing intake activities only for new beneficiaries (that is, beneficiaries starting treatment at the OTP)
- There are four add-on codes that describe take-home doses of medication that can be billed in addition to one of the bundled payment codes for a weekly episode of care
- HCPCS code G2078 take-home supplies of methadone:
- Up to seven additional days of medication
- Can be billed along with the respective weekly bundled payment code in units of up to three (for a total of up to a one-month supply)
- The add-on code for take-home doses of methadone can only be used with the methadone weekly episode of care code (HCPCS code G2067)
- The date of service may reflect either the actual date you provided the medication to the beneficiary or may correspond with the first day in the weekly billing cycle for the week in which the beneficiary received the take-home supply of medication
- HCPCS code G2079 take-home supplies of oral buprenorphine:
- Up to seven additional days of medication
- Can be billed along with the base bundle in units of up to three (for a total of up to a one-month supply)
- Can only be used with the oral buprenorphine weekly episode of care code (HCPCS code G2068)
- Allows a maximum take-home supply of one month of medication
- The date of service may reflect either the actual date you provided the medication to the beneficiary or may correspond with the first day in the weekly billing cycle for the week in which the beneficiary received the take-home supply of medication
- HCPCS code G2215 take-home supply of nasal naloxone
- HCPCS code G2216 take-home supply of injectable naloxone:
- When submitting a claim for HCPCS code G2216, OTPs must note the dosage that was dispensed to the beneficiary in the units field of the claim form (box 24G of the 1500 or Form Locator 46 of the UB-04), rounded to the nearest whole number (with a minimum dosage of 1mg)
- HCPCS code G2078 take-home supplies of methadone:
- HCPCS code G1028 take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 ml nasal
- HCPCS code G2080 may be billed when you provide counseling or therapy services that substantially exceed the amount specified in the beneficiary’s individualized treatment plan. OTPs are required to document the medical necessity for these services in the beneficiary’s medical record
Billing Cycles
OTPs may choose to apply a standard billing cycle by setting a particular day of the week to begin all episodes of care. In this case, the date of service would be the first day of the OTP’s billing cycle. If a beneficiary starts treatment at the OTP in the middle of the OTP’s standard weekly billing cycle, the OTP may still bill the applicable code for that episode of care provided that it meets the threshold to bill for the code.
OTPs may also choose to adopt weekly billing cycles that vary across beneficiaries. Under this approach, the initial date of service will depend on the day of the week when the beneficiary was first admitted to the program or when Medicare billing began. With this approach, when a beneficiary is beginning treatment or re-starting treatment after a break in treatment, the date of service would be the first day the beneficiary was seen and the date of service for subsequent consecutive episodes of care would be the first day after the previous seven-day period ends.
Reviewed 9/3/2024