Billing & Payment

Billing & Payment

COVID-19: CMS Allowing Audio-Only Calls for OTP Therapy, Counseling, and Periodic Assessments

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 (HCPCS code G2080) for beneficiaries with opioid use disorders, provided all other requirements are met. Providers may conduct the periodic patient assessments (HCPCS 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.

This change, effective March 1, 2020, is necessary so beneficiaries without access to interactive audio-video communication technology can continue receiving these important services.

This will apply for the duration of the public health emergency for the COVID-19 pandemic.  OTPs should continue to use Place of Service code 58 on claims for all OTP services, including those furnished using audio-video or audio-only communication technology.

Overview

As of January 1, 2020, Medicare pays enrolled Opioid Treatment Programs (OTPs) bundled payments based on weekly episodes of care for services including:

  • FDA-approved treatment medications for the treatment of OUD
  • The dispensing and administration of such medications (if applicable)
  • Substance use counseling
  • Individual and group therapy
  • Toxicology testing

Medicare will also adjust payments for the bundled payment amount for intake activities and periodic assessments, which are required by SAMHSA, as well as for additional counseling and therapy, and take-home supplies of medications.

There is NO copayment for OTP services for people with Medicare.

Review the OTP Medicare Billing & Payment Booklet (PDF) to learn about:

  • Covered opioid use disorder (OUD) Treatment Services
  • Coding and submitting claims for OTP services
  • Payment and remittance advice (RA)

If you’re a clinician, visit the office-based OUD treatment services webpage for more information on billing.  Clinicians can’t use OTP codes to bill for office-based treatment.

The CY 2022 National Final Unadjusted Payment Rates for OTPs (PDF) describe OTP HCPCS G-codes, bundled payments, and the total unadjusted payment assigned to each rate code. 

CMS adjusts the non-drug component of the OTP bundled payments for geographic locality so payment rates will vary depending on the OTP’s location.  CMS also geographically adjusts the add-on payments for non-drug services (i.e., intake activities, periodic assessments, additional counseling and therapy).

New for Calendar Year (CY) 2022

The CY 2022 Physician Fee Schedule final rule includes information for Medicare-enrolled OTPs:

  • After the end of the COVID-19 public health emergency (PHE), CMS will allow audio-only interactions (such as telephone calls) for counseling and therapy in cases where audio-video communication isn’t available to the patient, including circumstances in which the patient can’t or won’t agree to the use of two-way audio/video communication.
  • CMS established a new code (HCPCS code G1028) for a higher dose of naloxone hydrochloride nasal spray in response to the increase in overdoses from illicitly-manufactured fentanyl, which can require a more potent overdose reversal drug

After the conclusion of the PHE, CMS expects OTPs to add the following modifiers on claims for HCPCS code G2080:

  • Modifier 95: for counseling and therapy provided using audio-video telecommunications
  • Modifier FQ: for counseling and therapy provided using audio-only telecommunications

Identifying CY 2022 Locality-Specific Payment Rates

  1. In the Locality Key (PDF) document, find the locality and MAC numbers assigned to your OTP based on the State/Fee Schedule Area/County location of your practice
  2. In the CY 2022 National Final Unadjusted Payment Rates for OTPs (PDF) document, find the HCPCS code for the service of interest
  3. In the Locality Adjusted Rates (PDF) document, find your locality and corresponding MAC numbers along with the HCPCS code to find the geographically-adjusted payment rate

2021

Identifying CY2021 Locality-Specific Payment Rates

  1. In the Locality Key (PDF) document, find the locality and MAC numbers assigned to your OTP based on the State/Fee Schedule Area/County location of your practice.
  2. In the CY 2021 National Final Unadjusted Payment Rates for OTPs (PDF) document, find the HCPCS code for the service of interest.
  3. In the Locality Adjusted Rates (PDF) document, find your locality and corresponding MAC numbers along with the HCPCS code to find the geographically-adjusted payment rate. We updated the CY2021 locality-adjusted rates for OTP services to reflect the Geographic Practice Cost Index work floor, which the Consolidated Appropriations Act, 2021 extended through Jan. 1, 2024.

2020

Identifying CY 2020 Locality-Specific Payment Rates

  1. In the Locality Key (PDF) document, find the locality and MAC numbers assigned to your OTP based on the State/Fee Schedule Area/County location of your practice
  2. In the CY2020 National Final Unadjusted Payment Rates for OTPs (PDF) document, find the HCPCS code for the service of interest
  3. In the Locality Adjusted Rates -  Updated August 10, 2020  (PDF) document, find your locality and corresponding MAC numbers along with the HCPCS code to find the geographically-adjusted payment rate

Resources

Page Last Modified:
03/31/2022 09:34 AM