()

50.1  Special Opioid Treatment Program Billing Requirements for Hospitals, Critical Access Hospitals, and Free -Standing Opioid Treatment Program Facilities  (Rev. 10521; Issued: 12- 16-20; Effective: 01 -01-21; Implementation: 01 -04-21)   Medicare Part B coverage is available for hospital outpatient Opioid Treatment Program services. A. Billing Requirement  Section 1861(s)(2)(HH)(jjj) of the Act requires that opioid use disorder treatment services would include the Food and Drug Administration (FDA)-approved opioid agonist and antagonist treatment medications, the dispensing and administration of such medicat ions (if applicable), substance use disorder counseling, individual and group therapy, toxicology testing, and other items and services that the Secretary determines are appropriate. Section 1861(s)(2)(HH)(jjj) defines OTPs as those that enroll in Medicare  and are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), accredited by a SAMHSA -approved entity, and meet additional conditions as the Secretary finds necessary to ensure the health and safety of individuals being furni shed services under these programs and the effective and efficient furnishing of such services.   Hospitals and CAHs report condition code 89 in FLs 18-28 (or electronic equivalent) to indicate the claim is for Opioid Treatment Program services. They must also report a revenue code and the charge for each individual covered service furnished. In additi on, hospital outpatient departments are required to report HCPCS codes. CAHs are not required to report HCPCS code for this benefit.   Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under an opioid treatment program. In addition, hospital outpatient departments are required to report HCPCS codes. Component billing assures that only those opioid treatment program services covered under 1861(s)(2)(HH)(jjj) of the Act are paid by the Medicare program.   All hospitals are required to report condition code 89 in FLs 18-28 to indicate the claim is for opioid treatment program services. Hospitals use bill type 013X and CAHs use bill type 085X. The following special procedures apply:   Bills must contain an acceptable revenue code. They are as follows:   Revenue Code  Description  0636  Drugs Requiring Detailed Coding  0900  Behavioral Health Treatment/Services  0914  Individual Therapy  0915  Group Therapy  0916  Family Therapy  0918  0919 0940 0944  Behavioral Health/Testing  Other Behavioral Health Treatments  General Classification  Drug Rehabilitation  0949  0953 Other Therapeutic Service  Chemical Dependency (Drug and Alcohol)   Hospitals other than CAHs are also required to report appropriate HCPCS codes.  Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes. Do not edit for the matching of revenue code to HCPCS.  NOTE : Information regarding the Form CMS -1450 form locators that correspond with these fields is found in Chapter 25 of this manual. See the ASC X12 837 Institutional Claim implementation guide for related guidelines for the electronic claim.   B. Reporting of Service Units   Hospitals and Free -Standing facilities report the number of times the service or procedure, as defined by the HCPCS code, was performed.   NOTE : Service units are not required to be reported for drugs and biologicals (Revenue Code 250).   C. Line Item Date of Service Reporting   Hospitals other than CAHs are required to report line item dates of service per revenue code line for opioid treatment program claims. This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the  service was provided for every occurrence. Line item dates of service are reported in FL 45 Service Date (MMDDYY).   D. Special Requirements for Free-Standing Opioid Treatment Program Facilities   Section 1833 (s)(2)(HH)(jjj))) of the Act recognizes Free -Standing Opioid Treatment Program Facilities as providers of services but only for furnishing Opioid Treatment Program services. Applicable provider ranges are xx9900-xx9999 billed on a claim with  a type of bill 087x.  Other billing requirements (except condition code 89 reporting) mentioned above for hospitals apply.   E. Payment   Section 1861 (s)(2)(HH)(jjj )) of the Act provides the statutory authority governing payment for opioid treatment program services provided by a hospital or free -standing facility.  A/B MAC(s) (A) make payment on a fee schedule basis (see 30.8).  CAHs are paid at reasonable cost bas is.  The Part B deductible applies.  There is no PC/TC split for OTP billing.  Only one (1) provider may bill for the services of the opioid treatment program, either the facility or the practitioner, but not both.       F. Data for CWF and PS&R   Include revenue codes, HCPCS/CPT codes, units, and covered charges in the financial data section (fields 65a - 65j), as appropriate. Report the billed charges in field 65h, "Charges," of the CWF record.   Include in the financial data portion of the PS&R UNIBILL, revenue codes, HCPCS/CPT codes, units, and charges, as appropriate.   G. Medical Review   The A/B MACs (A) follow medical review guidelines in Pub. 100-08, Medicare Program Integrity Manual.        Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12418CP  12/21/2023 Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Opioid Treatment Programs (OTPs)  01/24/2024 13470 R11792CP  01/19/2023 Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Opioid Treatment Programs and Additional Claims Modifier for Audio -only Services  02/21/2023 13062 R11219CP  01/27/2022 Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Opioid Treatment Programs and New Modifier for Audio- only Services  03/01/2022 12545 R10665CP  03/16/2021 Updates to Medicare Benefit Policy Manual and Medicare Claims Processing Manual for Opioid Treatment Programs (Manual Updates Only)  04/15/2021 12161 R10521CP  12/16/2020 New Medicare National Uniform Billing Committee (NUBC) Type of Bill (TOB), Condition Code and implementing Billing Codes for Opioid Treatment Programs  01/04/2021 11856  08/06/2020 New Medicare National Uniform Billing Committee (NUBC) Type of Bill (TOB), Condition Code and implementing Billing Codes for Opioid Treatment Programs  Rescinded and replaced by transmittal 10521 01/04/2021 11856  02/14/2020 Update to Medicare Benefit Policy Manual and Medicare Claims Processing Manual Adding New Chapters for Opioid Treatment Programs (Manual Updates Only  03/16/2020 11620 Back to Top of Chapter