Requirements for an Episode

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 patient’s 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 G2074) 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 services 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 weekly 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.