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Medicare Claims Processing Manual  Chapter 39  Opioid Treatment Programs (OTPs)  Table of Contents  (Rev. 12418; Issued: 12- 21-23)  Transmittals for Chapter 39   10 - General    20 - Statutory authority for OTPs billing Medicare    30 - Bundled payments for Opioid Use Disorder (OUD) treatment services    30.1 -  Duration of bundle      30.2 -  Requirements for an Episode     30.3 -  Non -drug episode of care     30.4 -  New drugs     30.5 -  Site of service (telecommunications)     30.6 -  Coding    30.6.1 -  Adjustments to Bundled Payment Rate     30.7 -  Cost Sharing   30.8 -  Locality Adjustments    30.9 -  Annual Updates   40 - Practitioner Claims submission  A/B MAC (B)   40.1 -  Place of Service    40.2 -  Date of Service      40.3 -  Prescribing Individuals   50  Institutional Opioid Treatment Program (OTP) Services  A/B MAC (A)   50.1 Special Opioid Treatment Program Billing Requirements for Hospitals, Critical Access Hospitals, and Free -Standing Opioid Treatment Program Facilities       10 - General  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  This chapter provides claims processing instructions for Opioid Treatment Programs (OTPs).   The Medicare Benefit Policy Manual, Chapter 17, provides coverage policy for OTPs.   20 - Statutory authority for OTPs billing Medicare  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  Section 2005 of the SUPPORT Act amended section 1861 of the Act by adding a new subsection (jjj)(2) to define an OTP as an entity meeting the definition of OTP in 42 CFR 8.2 or any successor regulation (that is, a program or practitioner engaged in opioid treatment of individuals with an opioid agonist treatment medication registered under 21 U.S.C. 823(g)(1)), that meets the additional requirements set forth in subparagraphs (A) through (D) of section 1861(jjj)(2) of the Act.  Specifically that the OTP: is  enrolled under section 1866(j) of the Act; has in effect a certification by the Substance Abuse and Mental Health Services Administration (SAMHSA) for such a program; is accredited by an accrediting body approved by SAMHSA; and meets such additional condi tions as the Secretary may find necessary to ensure the health and safety of individuals being furnished services under such program and the effective and efficient furnishing of such services.  We defined opioid treatment program at  410.67(b) as an entity that is an OTP as defined in  8.2 (or any successor regulation) that meets the applicable requirements for an OTP. For an OTP to participate and receive payment under the Medicare program, the OTP must be enrolled under section 1866(j) of the Act, have in effect a certification by SAMHSA for such a program, and be accredited by an accrediting body approved by SAMHSA.   30 - Bundled payments for Opioid Use Disorder (OUD) treatment services  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  The bundled payment rates are calculated by combining the drug component and the non- drug components.  30.1 - Duration of bundle  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  An episode of care is defined at  410.67(b) as a 1 -week (contiguous 7- day) period.   There is no maximum number of weeks for a course of treatment for OUD.   30.2 - Requirements for an Episode  (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)  In recognition that there is a range of service intensity depending on the severity of a patients OUD and stage  of treatment,  a full  weekly  bundle  may consist  of a very different  frequency  of services for  a patient in the initial phase of treatment compared to a patient in the maintenance phase of treatment, or based on other factors such as pregnancy or relapse.  The threshold to bill the weekly episode is the delivery of at least one service in the weekly bundle (from either the drug or non- drug component) to the patient during the week that corresponds to the episode of care.  If no drug was provided to the patient  during that episode, the OTP must  bill the G-code  describing the weekly bundle not including the drug (HCPCS code G 2074) and the threshold to bill would be at least one service in the non- drug component. If a drug was provided with or without additional non- drug component services, the appropriate  G-code  describing the weekly  bundle  that includes  the drug furnished  may be billed.   For OTP intensive outpatient services, the threshold to bill HCPCS code G0137 for these services is a minimum of nine services furnished over a 7 -continguous day period. These services are described in  410.67(b)(ix) in the definition of OTP intensive outpatient services. A minimum of nine OTP intensive outpatient services, regardless of the length or time duration of these services, meets the threshold to bill, including if services of the same type are furnished more than once a week as long as all ser vices are medically reasonable and necessary for the treatment of OUD. However, an OTP may not count an intensive outpatient program service for the purposes of the nine -service threshold if that same service is being used to qualify for billing other week ly bundles and add- on codes under the OTP benefit. Additionally, to bill HCPCS code G0137, a physician or non-physician practitioner (as defined in section 1842(b)(18)(C) of the Act) must certify that the individual has a need for a minimum of nine hours of services per week and requires a higher level of care intensity compared to other non- intensive outpatient OTP services. A physician or non-physician practitioner, as permitted by state law and scope of practice requirements, must also meet requirements for certification, plan of treatment, and recertification requirements as set forth in  424.24(d)(1) through (3)  for the purposes of furnishing OTP intensive outpatient services.   30.3 - Non-drug episode of care  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  HCPCS code G2074 describes a non- drug episode of care. This provides a mechanism for OTPs to bill for non-drug services, including substance use counseling, individual and group therapy, and toxicology testing, that are rendered during weeks when a medicat ion is not administered, for example, in cases where a patient is being treated with injectable buprenorphine or naltrexone on a monthly basis or has a buprenorphine implant.   30.4 - New drugs  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  We anticipate that there may be new Food and Drug Administration (FDA) -approved opioid agonist and antagonist treatment medications to treat OUD in the future.   OTPs may bill for an episode of care using the medication not otherwise specified (NOS) code (HCPCS code G2075) in the scenario where an OTP furnishes MAT using a new FDA -approved opioid agonist or antagonist medication for OUD treatment that is not specif ied in one of our existing codes. In such cases, the typical or average maintenance dose would be used to determine the drug cost for the new bundle, which contractors would then add to the non- drug component payment amount that corresponds with the releva nt payment for drug administration (oral, injectable, or implantable) to determine the total bundled payment for the episode of care. Pricing for the drug component should be determined based on the relevant pricing methodology as described in the CY 2020 Physician Fee Schedule final rule or through invoice pricing in the event the information necessary to apply the relevant pricing methodology is not available.   30.5 - Site of service (telecommunications)  (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)  OTPs can use two -way interactive audio -video communication technology, as clinically appropriate, to furnish the substance use counseling and individual  and group therapy services included in the bundled payment, as well as the add -on code for additional counseling and therapy. During the Public Health Emergency (PHE) for the COVID -19 pandemic, and following the end to the PHE  on May 11th, 2023, the therapy and counseling portions of the weekly bundles of services furnished by OTPs, additional counseling or therapy payable under the add-on code for additional counseling or therapy, and  the OTP  intake  add-on code  for the initiation  of treatment  with buprenorphine  (but not methadone), may be furnished using audio -only telephone calls rather than via two- way interactive audio-video communication technology if beneficiaries do not have access to two -way audio/video communications technology, provided all other applicable requirements are met. This includes instances when the beneficiary is not capable of, or does not consent to, the use video technology for the service.   Beginning January 1, 2021, periodic assessments may be furnished via two-way interactive audio-video communication technology, as clinically appropriate, and in compliance with all applicable requirements, and in cases where a beneficiary does not have access to two-way audio-video communications technology, periodic assessments  can be furnished using audio -only  telephone  calls  during the PHE  and through the end of CY 2024 if all other applicable requirements are met.   OTPs providing intensive outpatient services to Medicare beneficiaries with an OUD shall not receive payment under Medicare part B if these services are furnished via audio- video or audio-only communications technology.   After the conclusion of the PHE for the COVID -19 pandemic , which ended on May 11, 2023, CMS expects OTPs to add Modifier 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio -only telecommunications system) to the claim for counseling and therapy provided via audio- only telecommunications using HCPCS code G2080, as well as for intake activities and periodic assessments furnished using audio- only communication technology. Additionally, CMS  expects  OTPs to add Modifier 95 (Synchronous  Telemedicine  Service  Rendered via  Real-Time  Interactive  Audio  and Video  Telecommunications  System)  to the claim  for counseling and therapy provided via audio- video telecommunications using HCPCS code G2080, as well as for intake activities and periodic assessments furnished using audio and video communication technology.   As OTP services are not PFS services, no originating site facility fee (HCPCS code Q3014) applies to OUD treatment services, and OTPs are not authorized to bill for the originating site facility fee. Additionally, the payment  for the substance  use counseling and individual  and group therapy are included  in the bundled  payment rates made to OTPs; therefore, the practitioner furnishing the service remotely should not bill separately for the service.   30.6  Coding  (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)  The codes describing bundled payments made to OTPs are HCPCS codes G2067- G2075. There are add- on codes described by HCPCS codes G2076- G2080, HCPCS codes G2215, G2216, G1028, and G0137 . Only an entity enrolled with Medicare as an OTP can bill these codes. Additionally, OTPs are limited to billing only these codes describing bundled payments, and may not bill for other codes, such as those paid under the PFS.   The coding structure for OUD treatment services varies by the medication administered. There are G codes for weekly bundles describing treatment with methadone, oral buprenorphine, injectable buprenorphine, buprenorphine implants (insertion, removal, and i nsertion/removal), extended- release injectable naltrexone, a non- drug bundle, and one for a medication not otherwise specified (see full list of codes below).