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Opioid Treatment Program (OTP) Questions and Answers

The following document was developed based on questions and answers posed during our webinars on the OTP benefit.

Comprehensive information on the OTP benefit can be referenced on Opioid Treatment Program (OTP).

Note: Unless otherwise specified, the following questions and answers apply to both Part A and Part B providers.

Enrollment

1Q. Are there specific documentation or treatment planning requirements required by Medicare?

1A. OTP providers should follow the Substance Abuse and Mental Health Services Administration (SAMHSA) regulations.

2Q. How long does it take to process the Medicare enrollment application?

2A. The enrollment process can vary; please refer to our CMS-855 Enrollment Application Processing Timeframes.

3Q. Who can I contact regarding the status of our enrollment application?

3A. The Enrollment Application Status Tool can verify the status of an OTP enrollment application. For additional questions regarding enrollment, please Contact Enrollment.

4Q. Do all services provided to opioid use disorder (OUD) patients have to be provided in the same location?

4A. OTP providers could potentially have multiple locations. OTP providers will need to include all practice locations on the enrollment application.

5Q. How do I enroll in Medicare as an OTP?

5A. An enrollment application is required to enroll in Medicare. The most efficient way to enroll is by submitting your application online through PECOS. If enrolling as a Part A OTP by paper, you must submit the CMS-855A enrollment application. If enrolling as a Part B OTP by paper, you must submit the CMS-855B enrollment application. For more information, visit our Enrollment page.

Coding and Billing

1Q. What place of service is used to bill OTP services (Part B)?

1A. Place of service 58 should be used to indicate a non-residential opioid treatment facility.

2Q. How are the add-on codes (AOCs) for take-home supplies of medication billed?

2Q. There are several codes describing take-home supplies of medication:

  • HCPCS code G2078 - take-home supplies of methadone - describes up to 7 additional days of medication and is billed along with the respective weekly bundled payment in units of up to 3 (for a total of up to a one-month supply). This add-on code is only used with the methadone weekly episode of care code (HCPCS code G2067).
  • HCPCS code G2079 - take-home supplies of oral buprenorphine- describes up to 7 additional days of medication and is billed along with the base bundle in units of up to 3 (for a total of up to a 1-month supply). This add-on code is only used with the oral buprenorphine weekly episode of care code (HCPCS code G2068).
  • HCPCS code G2215 - take home supply of nasal naloxone; 2 pack of 4mg per 0.1 mL spray. This add-on code should be reported in addition to the primary procedure.
  • HCPCS code G2216 - take home supply of injectable naloxone. This add-on code should be reported in addition to the primary procedure.
  • HCPCS code G1028 - take-home supply of nasal naloxone; 2-pack of 8mg per 0.1m mL nasal. This add-on code should be reported in addition to the primary procedure.
  • Note: Payment for add-on HCPCS code G1028 is limited to once every 30 days unless an additional take-home supply of the medication is medical reasonable and necessary.
  • HCPCS code G0532 - take-home supplies of nasal nalmefene hydrochloride (bill once every 30 days)

3Q. What new AOCs can be used with primary codes G2067-G2069, G2073-G2075, and G0533?

3A. New AOCs HCPCS codes include:

4Q. Are there frequency limits on the AOCs?

4A. CMS outlines frequency of use guidelines OTP Billing & Payment page.

5Q. Is there a limit to how often a patient can receive treatment for OTP services?

5A. There is no limit to how often patients can receive OTP services.

6Q. Are prior authorizations required for OTP services?

6A. OTP services do not require prior authorization.

7Q. What's the definition for "new patient"? Say if a patient is back after being absent for more than 30 days from the OTP facility, will the patient be regarded as "new patient"?

7A. The add-on code, G2076, indicates the intake activities should only be billed for new patients starting OUD treatment at an OTP for medically reasonable and necessary services. When reporting G2076, it must be reported with either the drug G2067-G2069, G2073, G2075 and G0533 or the non drug bundle code G2074.

8Q. What is considered a bundled payment for OTP services?

8A. Each bundled payment consists of a drug component or a non-drug component. The drug component includes the FDA-approved opioid agonist and antagonist treatment medications, dispensing and or administration of medication, substance use counseling, individual and group therapy, and toxicology testing. The non-drug component includes payment for substance use counseling, individual and group therapy, and toxicology testing.

9Q. Client will go from program to program frequently. Will a client be eligible to receive a new assessment if they leave the program for more than 31 days?

9A. Yes. If the patient is new and/or has been away, they can bill an intake activity add-on code.

10Q. Can you give us examples when an OTP could bill for additional counseling?

10A. The add-on code, G2080, describes each additional 30 minutes of counseling in a week. Threshold to bill G2080 is when the amount of counseling would go above and beyond the typical amount of counseling that patient is getting, as specified in his/her individualized treatment plan.

Example: Prompted by relapse, clinical team decides the patient needs additional counseling sessions that week.

When reporting G2080, it must be reported with drug bundled codes G2067-G2069, G2073, G2075 and G0533.

11Q. Are there circumstances when more than one OTP can bill for the same beneficiary in the same week?

11A. When a special billing situation arise patients may be appropriately given OUD services at more than one OTP within a 7 continuous day period in certain limited clinical situations: Such as guest dosing or when a patient transfers care between OTP. Each of the involved OTPs may bill the appropriate HCPCS codes for the services given to the patient. Both the OTPs must maintain sufficient medical record documentation to reflect the clinical situation and services provided.

12Q. Are drug screenings included in the G visit codes?

12A. The toxicology screening is included in the bundled payment for the drug and non-drug component.

13Q. If we bill OUD services from physician-based clinic, are they covered under the Medicare program or only covered when provided by an OTP?

13A. The clinic needs to be OTP certified. OTP is limited to outpatient services only.

14Q. If a patient comes in for their dose of Methadone for seven days and received no other services, would we bill G2067?

14A. Yes, the OTP would bill G2067.

15Q. If a physician provides an assessment service in an OTP setting, what code would the OTP bill?

15A. The intake activity code G2076 should be billed describing the intake activities outlined in the HCPCS descriptor. In addition, because this is an add on code it should be billed with one of the primary codes G2067-G2069, G2073, G2075 and G0533.

Additional information on coding and billing including HCPCs descriptors for OTP services, please refer to the CMS page OTP Billing & Payment.

16Q. How do I bill for OTP therapy, counseling, and periodic assessment via telehealth?

16A. CMS revised regulation text to allow audio-only telephone calls for the therapy and counseling portions of the weekly bundles and the add-on code for additional counseling or therapy (code G2080) for beneficiaries with opioid use disorders, provided all other requirements are met.

Providers may conduct the periodic patient assessments (code G2077) via two-way interactive audio-video communication technology or by telephone only in cases where the beneficiary does not have access to two-way interactive technology.

Use the following HCPCS AOCs for patients with OUD who meet all other requirements:

  • G2076 to initiate treatment with buprenorphine provided via 2-way, interactive, audio-video or audio-only technology when audio-video technology isn’t available.
  • G2077 for periodic patient assessments via audio-video technology
  • G2080 for additional counseling or therapy via audio-only technology when audio-video technology isn’t available.

The following modifiers need to be reported on HCPCS codes G2076, G2077, and G2080:

  • Modifier 95: for counseling and therapy provided using audio-video technology.
  • Modifier 93: for counseling and therapy provided using audio-only technology.

Refer to the OTP Billing & Payment page.

17Q. How do I bill for G2216 to ensure I am receiving the proper payment?

17A. Procedure code G2216 should be billed in addition to the primary procedure. OTPs must note the dosage that was dispensed to the beneficiary in the units of service field on the claim form:

  • Part A UB-04 claim for report in form locator 46.
  • Part B CMS 1500- claim form report in item 24G or the EDI equivalent.

The units of service should be rounded to the nearest whole number with the minimum dosage of 1mg.

18Q. How should an OTP provider bill for their weekly bundle when a prescription is being written, and the patient had substance abuse counseling, individual and group therapy as well as toxicology testing?

18A. Procedure code G2074 should be used when the weekly bundle doesn't include the dispensing or administration of the medication. The prescription can be filled at the patient's pharmacy, and the pharmacy can bill the Part D program.

Ensure when a prescription is written, the weekly MAT codes (G2067-G2069, G2073, G2075 and G0533) as well as take home supplies (G0532, G2078, G2079, G2215, G2216 and G1028) aren't billed to the patient's Part D provider.

19Q. What type of bill (TOB) do I report if I am a free-standing OTP facility (Part A)?

19A. Free-standing OTP facilities use TOB 087X.

20Q. Do I need to report condition code (CC) 89 if I am a free-standing OTP facility (Part A)?

20A. No. Only hospital-based OTP providers that bill on TOB 13X or 85X must report CC 89.

21Q. What revenue code(s) should I use when reporting OTP services (Part A)?

21A. Revenue code(s) 090X-091X, 0949, and 0953 are to be used when billing for OTP services.

Reimbursement

1Q. How do I determine my payment for the OUD services?

1A. The national payment rates are available on the Final Rule Payment Rates for Opioid Treatment Programs

Other Billing Situations

1Q. Can Medicare Advantage plans offer the OTP benefit?

1A. Medicare Advantage (MA) plans must include the OTP benefit and can contract with OTP providers in their service area. In covering the OTP benefit, MA plans must use only OTP providers that meet the same requirements as those providing services under Medicare Part B (including enrollment with Medicare).

OTPs should contact MA Plan Directory  and ask for "provider services" to assist with questions about payment for OTP services under that patients MA plan.

2Q. How can we determine if a patient has an MA plan?

2A. There are several ways to obtain patient eligibility information relating to MA plans.

Our SPOT portal offers an eligibility feature, which outlines all eligible plans including MA plan information for a beneficiary. For additional information on all the valuable features SPOT has to offer, or how to begin the enrollment process, visit our SPOT page.

3Q. How will Medicaid payments be made while our application is awaiting approval by Medicare?

3A. Medicare is the primary payer for OTP services for dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who currently receive OTP services through Medicaid.

Medicaid must pay for services delivered to these beneficiaries who are not yet enrolled in Medicare but are enrolled in Medicaid. Once the OTP provider becomes Medicare eligible, those payments will be recouped from Medicaid back to the effective date of the OTP's Medicare enrollment, and the OTP will then bill Medicare for those services.

4Q. How do intensive outpatient program (IOP) services for OUD get billed by an OTP?

4A. OTPs bill for the intensive outpatient services as an add-on code to the OTP services with HCPCS code G0137.

When billing for IOP services for OTP report the appropriate MAT or non-drug bundle code with HCPCS code G0137 (IOP services).

Threshold to bill IOP for OUD services is a minimum of nine services over a seven-contiguous day period.

For more information refer to CMS IOM Pub.100-04 Medicare Claims Processing Manual, Chapter 39, Section 30.6.1 and MLN Booklet MLN1986542, Medicare and Mental Health Coverage.

Physician Coding

1Q. Can physicians bill for the G2067 - G2080 and receive the bundled payment?

1A. Only OTPs can bill for the G codes and receive payment. Physicians can bill for the office-based procedure codes G2086-G2088.

2Q. Would the physicians be able to bill the office-based codes G2086-G2088 within the location of service at the hospital, ER, and psychiatric unit?

2A. HCPCS codes G2086-G2088 can be billed for an episode of substance use disorder (SUD) treatment furnished by physicians and other practitioners in the office setting.

3Q. What services are included in the office-based SUD treatment procedures G2086-G2088?

3A. Office-based treatment codes include the overall management, care coordination, individual and group counseling, substance use counseling and an add-on code for additional counseling. For additional information refer to Office-Based Substance Use Disorder (SUD) Treatment Billing.

Miscellaneous

1Q. How often is Medicare eligibility updated on SPOT?

1A. The information is pulled from the HIPPA Eligibility Transaction System and will be updated routinely.