Billing & Payment

Spotlight 

OTP G-codes for intake activities

Use the G-Codes Frequency of Use Guidelines on this page when billing OTP G-codes. Use intake activity code G2076 only to bill for new patients starting OUD treatment at an OTP for medically reasonable and necessary services.

Medicare pays enrolled OTPs bundled payments for opioid use disorder (OUD) treatment based on weekly episodes of care.

Professionals who can provide substance use counseling and individual and group therapy included in the bundled payment may include but isn’t limited to:

  • Licensed clinical social workers
  • Licensed professional counselors/mental health counselors
  • Licensed marriage and family therapists
  • Licensed clinical alcohol and drug counselors
  • Certified peer specialists
  • Other professionals permitted to give this type of therapy or counseling by state law and scope of practice

There’s NO copayment for OTP services for Medicare patients but the Part B deductible does apply. Check your patient’s Medicare eligibility.

If you’re a clinician, visit Office-Based Substance Use Disorder (SUD) Treatment Billing and Opioid Use Disorder Screening & Treatment for more information. Clinicians can’t use OTP codes to bill for office-based treatment.

How to Bill

Institutional Providers

You bill on the Form CMS-1450 using:

  • Type of Bill (TOB) code (087x) for freestanding non-residential OTP
  • Condition code (89) for provider-based OTP
  • TOB 013x for hospital based and TOB 085x for Critical Access Hospitals-based OTP services
  • Revenue codes 090x-091x, 0949 on TOB 013x, 085x, or 087x for OTP services

Professional Providers

You bill on the Form CMS-1500 (PDF) using:

  • Place of Service (POS) code 58 (Non-Residential Opioid Treatment Facility)
  • HCPCS codes associated with the OTP service
  • Codes describing add-on services, including the date the service
  • NPI of the person prescribing or ordering medication
  • Organizational NPI as the billing provider

Bill a Full Episode of Care

Be sure to provide at least 1 service (from either the drug or non-drug component) to the patient during the week that corresponds to the episode of care.

If you don’t provide a drug to the patient during that episode, bill the G-code describing a weekly bundle without including the drug (HCPCS code G2074), and then bill at least 1 service in the non-drug component.

If you provide a drug with or without additional non-drug component services, bill the appropriate G-code describing the weekly bundle including the drug.

G-Codes Frequency of Use Guidelines

These rules apply when billing OTP G-codes:

HCPCS CodeShort DescriptorDosDon’ts
G2067Medication-assisted treatment, methadoneUse to cover episodes of care lasting 7-days in a rowDon’t bill for same patient more than once for 7-day period
G2068Medication-assisted treatment, buprenorphine (oral)

· Use to cover episodes of care lasting 7-days in a row

· Can bill with buprenorphine combination products (buprenorphine and naloxone)

· Can bill with a buprenorphine-only product

Don’t bill for same patient more than once for 7-day period
G2069Medication-assisted treatment, buprenorphine (injectable)Use to cover episodes of care lasting 7-days in a row

· Don’t bill for same patient more than once for 7-day period

· Don’t use more than once every 4 weeks

G2070Medication-assisted treatment, buprenorphine (implant insertion)Use to cover episodes of care lasting 7-days in a row

· Don’t bill for same patient more than once for 7-day period

· Don’t use more than once every 6 months

G2071Medication-assisted treatment, buprenorphine (implant removal)Use to cover episodes of care lasting 7-days in a rowDon’t bill for same patient more than once for 7-day period
G2072Medication- assisted treatment, buprenorphine (implant insertion and removal)Use to cover episodes of care lasting 7-days in a row

· Don’t bill for same patient more than once for 7-day period

· Don’t use more than once every 6 months

G2073Medication-assisted treatment, naltrexoneUse to cover episodes of care lasting 7-days in a row

· Don’t bill for same patient more than once for 7-day period

· Don’t use more than once every 4 weeks

G2074Medication-assisted treatmentUse to cover episodes of care lasting 7-days in a rowDon’t bill for same patient more than once for 7-day period
G2075Medication-assisted treatmentUse to cover episodes of care lasting 7-days in a rowDon’t bill for same patient more than once for 7-day period
G2076 (add-on code)Intake activitiesBill only for new patients starting OUD treatment at an OTP for medically reasonable and necessary services 
G2077 (add-on code)Periodic AssessmentCan bill in addition to 1 of the bundled payment codes for a weekly episode of care for medically reasonable and necessary services 
G2078* (add-on code)Take-home supply of methadone

· Can bill in addition to 1 of the bundled payment codes for a weekly episode of care

· Bill up to 7 additional days of medication

· Bill along with the respective weekly bundled payment code in units of up to 3 (for a total of up to a 1-month supply)

· Use only for take-home doses of methadone with the methadone weekly

· Allows a maximum take-home supply of 1 month of medication

  • Don’t bill more than 3 times in 1 month (in addition to the weekly bundled payment code)
  • Don’t bill for take-home supplies of medication for dates of service that overlap with the weekly bundled payment codes describing a medication bundle (G2067-G2073)
G2079* (add-on code)Take-home supply of buprenorphine (oral)

· Can bill in addition to 1 of the bundled payment codes for a weekly episode of care

· Bill up to 7 additional days of medication

· Bill along with the base bundle in units of up to 3 (for a total of up to a 1-month supply)

· Use only with the oral buprenorphine weekly episode of care code (HCPCS code G2068)

· Allows a maximum take-home supply of 1 month of medication

  • Don’t bill more than 3 times in 1 month (in addition to the weekly bundled payment code)
  • Don’t bill for take-home supplies of medication for dates of service that overlap with the weekly bundled payment codes describing a medication bundle (G2067-G2073)
G2080 (add-on code)Each additional 30 minutes of counseling in a week of medication-assisted treatmentBill when you provide medically reasonable and necessary  counseling or therapy services that largely exceed the amount listed in the patient’s individualized treatment plan 
G2215 (add-on code)Take-home supply of nasal naloxoneBill only once every 30 days unless an additional take-home supply of the medication is medically reasonable and necessary 
G2216 (add-on code)Take-home supply of injectable naloxoneBill only once every 30 days unless an additional take-home supply of the medication is medically reasonable and necessary 
G1028 (add-on code)Take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 mL nasal sprayBill only once every 30 days unless an additional take-home supply of the medication is medically reasonable and necessary 
G0137 (add-on code)Intensive outpatient program (IOP) services  Use to cover episodes of care lasting 7-days in a row
  • Don’t bill if the patient didn’t receive at least 9 IOP services in a week
  • Don’t bill if the patient doesn’t have a need for a minimum of 9 hours of IOP services a week
  • Don’t bill if the patient doesn’t  require a higher level of care intensity compared to other non-intensive outpatient OTP services

*The date of service for HCPCS codes G2078 and G2079 may reflect either the actual date you provide the medication to the patient or the first day in the weekly billing cycle for the week the patient gets the take-home supply of medication.

Additional Notes:

  • If a patient switches from 1 drug to another, bill for 1 code describing a weekly bundled payment for that week. Use the code for the drug you gave the patient for most of the week.
  • You may give Medicare patients OUD services at more than 1 OTP within a 7-day period in certain, limited clinical situations, like guest dosing or when a patient transfers care between OTPs. Each of the involved OTPs may bill the appropriate HCPCS codes for the services, but both OTPs must maintain enough medical record documentation to show the clinical situation and services provided.
  • You can bill for medically reasonable and necessary services provided via mobile units.
Telecommunications

 Use the following HCPCS add-on codes 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

Use the following HCPCS add-on code through the end of CY 2024 for patients who meet all other requirements:

  • G2077 for periodic patient assessments via audio-only technology when audio-video technology isn’t available
Billing Cycle

Standard Billing Cycle

For the codes describing a weekly bundle (HCPCS codes G2067 to G2075), 1 week is defined as 7 days in a row. You can apply a standard billing cycle by choosing a particular day of the week to begin all episodes of care. In this case, the date of service is the first day of your standard weekly billing cycle. If a patient starts treatment in the middle of your standard weekly billing cycle, bill the applicable code for that episode of care if it meets the limit to bill for the code.

Weekly Billing Cycle

You can also adopt weekly billing cycles that vary depending on the patient. The initial date of service will depend on the day of the week when the patient is first admitted to the program or when Medicare begins billing. With this approach, when a patient is beginning treatment or re-starting treatment after a break in treatment, the date of service is the first day you see the patient. The date of service for later following episodes of care is the first day after the previous 7-day period ends.

For the codes describing add-on services (HCPCS codes G2076 to G2080 and G2215 to G1028), the date of service should show the actual date you provide the service to the patient. However, if you choose to apply a standard weekly billing cycle, the date of service is the same as the first day in the weekly billing cycle.

Claims
  • File claims as soon as possible and no later than 1 calendar year after the date of service. Your Medicare Administrative Contractor (MAC) may deny your claim if you file it 12 months or later after the DOS.
  • Use the POS code 58 on claims for all OTP services, including those provided via 2-way, interactive, audio-video or audio-only technology. For claims with dates of service on or after May 12, 2023, add these modifiers on claims for 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
  • When submitting a claim for HCPCS code G2216 (take-home supply of injectable naloxone), note the dosage dispensed to the patient in the units field of the claim form (box 24G of the CMS-1500 or Form Locator 46 of the UB-04), rounded to the nearest whole number (with a minimum dosage of 1mg).
Payment Rates

The CY 2024 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System final rule:

  • Establishes a weekly payment adjustment for IOP services provided by an OTP for OUD treatment. The IOP service:
  • Must be medically reasonable and necessary 
  • Can’t be duplicative of any service paid for under any bundled payments billed for an episode of care in a given week

The Final Rule Payment Rates for OTPs describe OTP HCPCS G-codes, drug cost, non-drug cost and the total cost assigned to each rate code. These rates show the national payment rates and don’t include adjustments based on locality. 

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

Locality-Specific Payment Rates 

2024

2023

Resources
Page Last Modified:
01/25/2024 08:42 AM