evekhm/cms_iom_500 huggingface dataset:
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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)
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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.
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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.
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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).   The code describing the bundled payment for an episode of care with a medication not otherwise specified (HCPCS code G2075) should be used when the OTP furnishes MAT with a new opioid agonist or antagonist treatment medication approved by the FDA under sec tion 505 of the FFDCA for the treatment of OUD. OTPs may use this code until CMS has the opportunity to propose and finalize a new G code to describe the bundled payment for treatment using that drug and price it accordingly in the next rulemaking cycle.   HCPCS code G2075 should not be used when the drug being administered is not a new opioid agonist or antagonist treatment medication approved by the FDA under section 505 of the FFDCA for the treatment of OUD, and therefore, for which Medicare would not have the authority to make payment since section 1861(jjj)(1)(A) of the Act requires that the medication must be an opioid agonist or antagonist treatment medication approved by the FDA under section 505 of the FFDCA for the treatment of OUD.   HCPCS code G2074, which describes a non- drug bundle, can be billed for services furnished during an episode of care when a medication is not administered, but other services in the bundle are furnished. For example, when a patient receives a buprenorphine injection on a monthly basis, the OTP will only require payment for the medication during the first week of the month when the injection is given, and therefore, would bill the code describing the bundle that includes injectable buprenorphine during the first week of the month and would bill the code describing the non- drug bundle for the remaining weeks in that month for services such as substance use counseling, individual and group therapy, and toxicology testing.
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NOTE: Some of the bundled payment codes describe a drug that is typically only administered once per month, such as the injectable drugs, or once in a 6 -month period, in the case of the buprenorphine implants. In those cases, the code describing the bundled payment that includes the cost of the drug would be billed during the week that the drug is administered, and if at least one service is furnished in a subsequent week, the non- drug bundle would be billed. For example, in the case of a patient receiving injectable buprenorphine, CMS would expect that HCPCS code G2069 would be billed for the week during which the injection was administered and that HCPCS code G2074, which describes a bundle not including the drug, would be bil led during any subsequent weeks that at least one non- drug service is furnished until the injection is administered again, at which time HCPCS code G2069 would be billed again for that week.   CMS notes that as HCPCS codes G2067  G2075, and G0137, cover episodes of care of 7 contiguous days, CMS will not permit an OTP to bill any of these codes for the same beneficiary more than once per 7 contiguous day period. Additionally, consistent with FDA labelling, CMS does not generally expect the codes d escribing bundled payments including the injectable drugs (HCPCS codes G2069 and G2073) to be furnished more than once every 4 weeks. Similarly, consistent with FDA labelling, CMS does not generally expect the codes describing bundled payments including insertion of the buprenorphine implants (HCPCS codes G2070 and G2072) to be furnished more than once every 6 months.
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CMS understands there are limited clinical scenarios when a beneficiary may be appropriately furnished OUD treatment services at more than one OTP within a 7 contiguous day period, such as for guest dosing or when a beneficiary transfers care between OTPs.  In these limited circumstances, each of the involved OTPs may bill the appropriate HCPCS codes that reflect the services furnished to the beneficiary. CMS expects that both OTPs involved would provide sufficient documentation in the patients medical record to reflect the clinical situation and services provided. Additionally, in instances in which a patient is switching from one drug to another, the OTP should only bill for one code describing a weekly bundled payment for that week and should determine which code to bill based on which drug was furnished for the majority of the week.    30.6.1 - Adjustments to Bundled Payment Rate  (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)  There are add -on codes for intake activities, periodic assessments, take- home supplies of methadone, take home  supplies  of oral buprenorphine, additional  counseling or therapy  services  furnished, and  for take-home supplies of naloxone.  CMS  notes  that the add-on code  describing intake  activities  (HCPCS  code  G2076)  should only be billed  for new patients (that is, patients starting treatment at the OTP).
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CMS  notes  that the add-on code  describing intake  activities  (HCPCS  code  G2076)  should only be billed  for new patients (that is, patients starting treatment at the OTP).   There are two add -on codes that describe take- home doses of medication, one for take -home supplies of methadone (HCPCS code G2078), which describes up to 7 additional days of medication, and can be billed along with the respective weekly bundled payment in units of up to 3 (for a total of up to a one month supply), and one for take -home supplies of oral buprenorphine (HCPCS code G2079), which also describes up to 7 additional days of medication and can be billed along with the base bundle in units of up to 3 (for a total of up to a 1 month supply). SAMHSA allows a maximum take -home supply of one month of medication;  therefore,  CMS  does not expect  the add-on codes  describing take- home  doses  of methadone  and oral buprenorphine to be billed any more than 3 times in one month (in addition to the weekly bundled payment). 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). Similarly, the add- on code for take -home doses of oral buprenorphine can only be used with the oral buprenorphine weekly episode of care code (HCPCS code G2068).   HCPCS code G2080 may be billed when counseling or therapy services are furnished that substantially exceed  the amount  specified  in the patients  individualized treatment  plan. OTPs  are required  to document the medical necessity for these services in the patients medical record.
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OTPs billing for intensive outpatient services (G0137) must be furnishing these services as part of a distinct and organized intensive ambulatory treatment program for the treatment of Opioid Use Disorder, and as part of a program that offers less than 24- hour daily care other than in an individual's home or in an inpatient or residential setting. By billing G0137, OTPs are attesting that these intensive outpatient services are reasonable and necessary for the diagnosis or active treatment of the individual 's condition; are reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization; and are furnished in accordance with a physician or non- physician practitioner (as defined in section 1842(b)(18)(C) of the Act) certification and plan of care, as permitted by State law and scope of practice requirements. A physician or non- physician practitioner 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. FDA -approved opioid agonist or antagonist medications for the treatment of OUD, opioid antagonist medications for the emergency treatment of known or suspe cted opioid overdose, or toxicology testing, do not count as payable OTP intensive outpatient services but if rendered, should be billed using existing bundles and/or add-on codes as long as all other applicable requirements are met.   The codes and  long descriptors  for the OTP  bundled services  and add-on services  are:   HCPCS code 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).    HCPCS code 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).
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 HCPCS  code  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).    HCPCS  code  G2070:  Medication  assisted  treatment,  buprenorphine  (implant insertion);  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).    HCPCS  code  G2071:  Medication  assisted  treatment,  buprenorphine  (implant removal);  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).    HCPCS code G2072: Medication assisted treatment, buprenorphine (implant insertion and removal); 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).   HCPCS code 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).    HCPCS code 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).    HCPCS  code  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).
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 HCPCS code G0137: Intensive outpatient services; minimum of nine services over a 7 - contiguous day period, which can include individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law); occupational therapy requiring the skills of a qualified occupational therapist; services of social  workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients; drugs and biologicals furnished for therapeutic purposes, excluding opioid agonist and antagonist medications that are FDA -approved for use in treatment of OUD or opioid antagonist medications for the emergency treatment of known or suspected opioid overdose; individualized activity therapies that are not primarily recreational or diversionary; family counseling (the primary purpose of which is treatment of the individuals condition); patient training and education (to the extent that training and educational activities are closely and clearly related to individuals care and treatment); diagnostic services (not including toxicology testing); (provision of the services by a Medicare -enrolled Opioid Treatment Program); List  separately in addition to code for primary procedure, if applicable    HCPCS code G2076: Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment conducted by a program physician or a primary care physician,  or an authorized  healthcare  professional  under  the supervision of a program  physician or qualified personnel that includes preparation of a treatment plan that includes the patients short -term goals and the tasks the patient must perform to complete the short -term goals; the patients requirem ents 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 Tr eatment Program); List separately in addition to code for primary procedure.    HCPCS  code  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.    HCPCS code 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.
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 HCPCS  code  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.    HCPCS  code  G2080:  Each  additional  30 minutes  of counseling or group or  individual  therapy  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.    HCPCS code 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.    HCPCS  code  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.    HCPCS code 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.   30.7 - Cost Sharing (Rev. 10665: Issued; 03- 16-21: Effective; 01 -01-21: Implementation: 04 -15-21)  There is zero beneficiary copayment for the codes billed by OTPs.  However, the Part B deductible does apply, as mandated for all Part B services by section 1833(b) of the Act.    30.8 - Locality Adjustments (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)
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30.8 - Locality Adjustments (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)  The payment amounts for the non- drug component of the bundled payment for an episode of care, and the adjustments for counseling or therapy, intake activities, periodic assessments, take -home supplies of naloxone, and intensive outpatient program services  (HCPCS codes G2067- G2077, G2080, G2215, G2216, G1028, and G0137) will be geographically adjusted using the Geographic Adjustment Factor (GAF). Additionally, for purposes of the GAF, OUD treatment services that are furnished via an OTP mobile unit will be treated as if they were furnished at the physical location of the OTP registered with the Drug Enforcement Administration (DEA) and certified by SAMHSA.   30.9 - Annual Updates    The payment  amounts  for the non-drug component  of the bundled payment for  an episode  of care, and  the adjustments for counseling or therapy, intake activities, periodic assessments, and intensive outpatient program services (HCPCS codes G2067-  G2077, G2080, and G0137) will be updated annually using the Medicare Economic Index.   40 - Practitioner Claims submission   A/B MAC (B)                                                        (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24) Beginning January  1, 2020, claims for OTP services are submitted using the 837P transaction to transmit health care claims electronically, or using the CMS -1500 (the paper version of the 837P). Beginning January 1, 2021, OTPs may apply on the Medicare Enrollment Application for Institutional Providers (CMS -855A)  or through the Internet -based  Provider  Enrollment,  Chain  and Ownership  System  (PECOS)(837I) when  they  enroll  in the Medicare Program.  These providers will  submit  claims  using the CMS -1450.   HCPCS  codes  G2067- G2075, and G0137, cover  episodes  of care of 7 continuous  days and cannot  be billed  for the same patient more than once per 7 continuous day period.