Coding

30.6 – Coding (Rev. 13147; Issued: 03-28-25; Effective: 01-01-25; Implementation: 03-25-25) The codes describing bundled payments made to OTPs are HCPCS codes G2067-G2069, G2073-G2075, and G0533. There are add-on codes described by HCPCS codes G2076-G2080, HCPCS codes G2215, G2216, G1028, G0137, G0532, and G0534-G0536. 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. 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, and injectable buprenorphine, monthly bundles describing treatment with extended-release injectable naltrexone and injectable buprenorphine, 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 section 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. Some of the bundled payment codes describe a drug that is typically only administered once per month, such as the injectable drugs. Consistent with FDA labelling, CMS does not generally expect the codes describing bundled payments including the monthly injectable drugs (HCPCS codes G2069 and G2073) to be furnished more than once every 4 weeks. 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 billed 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 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 patient’s 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. Modifier 59 CMS notes that as HCPCS codes G2067 – G2069, and G2073-G2075, 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. However, there may be certain circumstances when the OTP has a valid reason for billing the bundled payments (G2067 – G2069 and G2073-G2075) more than once in a 7-day period, such as when a patient is first beginning treatment and the OTP needs to synch that patient up with the OTP’s standard weekly billing cycle, or during holiday weeks when the OTP may be closed for a portion of the week. In these circumstances when the OTP has a valid reason for billing these bundles more than once per 7 contiguous day period, OTPs should append modifier 59 to the claim and document the valid reason (including providing sufficient documentation) for billing more than one bundled payment for an episode of care.