Adjustments to Bundled Payment Rate

30.6.1 - Adjustments to Bundled Payment Rate (Rev. 13572; Issued: 03-03-26; Effective: 01-01-26; Implementation: 06-02-26) 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, take-home supplies of naloxone, intensive outpatient program services, take-home supplies of nalmefene, coordinated care and/or referral services, patient navigational services, and peer recovery support services. 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 patient’s individualized treatment plan. OTPs are required to document the medical necessity for these services in the patient’s medical record. 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 suspected 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. OTPs may furnish evidence-based assessments as part of intake activities (HCPCS code G2076) and periodic assessments (HCPCS code G2076), as long as these assessments are medically reasonable and necessary for the diagnosis or treatment of an OUD. OTPs should have a reason to believe unmet needs or the need for harm reduction intervention or recovery support services identified during such an assessment could interfere with the OTP’s ability to diagnose or treat the patient’s OUD. CMS does not require that OTPs utilize a specific assessment tool when furnishing evidence-based assessments, but CMS expects that these tools are validated and will allow the OTP to identify more specific individual-level needs as part of the care plan, including considerations to potential harm reduction interventions and recovery support service needs. CMS requires that when billing for evidence-based assessments as part of intake activities (HCPCS code G2076) and periodic assessments (HCPCS code G2076), that OTPs continue to abide by SAMHSA certification requirements at § 8.12(f)(4). CMS notes that since intake activities may only be billed for new patients (that is, patients starting treatment at the OTP), additional evidence-based assessments provided following intake at an OTP should be billed as part of periodic assessments (HCPCS code G2076), as long as all other requirements are met. OTPs may additionally bill G0534 for coordinated care and/or referral services, when an OTP coordinates care or provides referral or linkage services to adequate and accessible community resources or community- based organizations that address a patient’s identified unmet needs, or the need and interest for harm reduction interventions and recovery support services, which may limit the ability of an OTP to diagnose or treat a patient’s OUD. These community-based organizations may include, but are not limited to, harm reduction organizations, peer support organizations, housing agencies, job training programs, recovery centers, food assistance or distribution programs, residential programs, and educational services. When a patient with an OUD requires additional navigational services to navigate multiple settings of care and to accomplish (Medications for opioid use disorder) MOUD treatment and recovery goals, they may qualify for patient navigational services (G0535) and/or peer recovery support services (G0536). OTPs can bill for patient navigational services or peer recovery support services when an OTP provides these services either directly or by referral. While OTPs may choose to refer patients with an OUD to peer recovery support services and patient navigation services outside the OTP, HCPCS codes G0535 and G0536 are only payable to OTPs. Patient navigational services help the patient with an OUD navigate multiple settings of care, including by identifying care providers or recovery supportive services, communicating with other health care or social service providers and securing appointments for patients, building patient self-advocacy and communication skills, and facilitating patient-driven goal-setting and action plans for MOUD treatment and recovery. OTPs can bill for peer recovery support services (G0536) that are performed by individuals either with knowledge of an OUD, or with lived experience of an OUD, and who provide support, coaching, mentorship, or inspiration to patients with an OUD to meet various MOUD treatment and recovery goals. These peer recovery support services may assist Medicare beneficiaries with an OUD to stay engaged in treatment at an OTP; connect patients with other peer support networks or recovery services in the community; conduct interviews of the patient to understand their background, needs, and goals, and then propose or strategize means for accomplishing such treatment and recovery goals. We expect OTPs document in the patient’s care plan how these aforementioned services (HCPCS codes G0534-G0536) relate to the diagnosis or treatment of an OUD prior to billing Medicare for these services. 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). ● HCPCS code G2069: Medication assisted treatment, buprenorphine (injectable) administered on a monthly basis; 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 G0533: Medication assisted treatment, buprenorphine (injectable) administered on a weekly basis; 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 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). ● 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 individual’s condition); patient training and education (to the extent that training and educational activities are closely and clearly related to individual’s 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 conducted by an appropriately licensed practitioner and preparation of a care plan, which may be informed by administration of a standardized, evidence-based assessment , and that includes the patient’s goals and mutually agreed-upon actions for the patient to meet those goals, including harm reduction interventions; the patient’s needs and goals in the areas of education, vocational training, and employment; and the medical and psychiatric, psychosocial, economic, legal, housing, physical activity and/or nutrition needs and other recovery support services that a patient needs and wishes to pursue, conducted by an appropriately licensed/credentialed personnel (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code. ● HCPCS code G2077: Periodic assessment; assessing periodically by an OTP practitioner and includes a review of MOUD dosing, treatment response, other substance use disorder treatment needs, responses and patient-identified goals, and other relevant physical, nutrition and psychiatric treatment needs and goals; may be informed by administration of a standardized, evidence-based assessment, or the need and interest for harm reduction interventions and recovery support services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code. ● 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. ● 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. ● HCPCS code G0532: Take-home supply of nasal nalmefene hydrochloride; one carton of two, 2.7 mg per 0.1 mL nasal sprays (provision of the services by a Medicare-enrolled Opioid Treatment Program);(List separately in addition to each primary code). ● HCPCS code G0534: Coordinated care and/or referral services, such as to adequate and accessible community resources to address unmet health-related social needs, including harm reduction interventions and recovery support services a patient needs and wishes to pursue, which significantly limit the ability to diagnose or treat an opioid use disorder; each additional 30 minutes of services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code). ● HCPCS code G0535: Patient navigational services, provided directly or by referral; including helping the patient to navigate health systems and identify care providers and supportive services, to build patient self-advocacy and communication skills with care providers, and to promote patient-driven action plans and goals; each additional 30 minutes of services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code). ● HCPCS code G0536: Peer recovery support services, provided directly or by referral; including leveraging knowledge of the condition or lived experience to provide support, mentorship, or inspiration to meet OUD treatment and recovery goals; conducting a person-centered interview to understand the patient’s life story, strengths, needs, goals, preferences, and desired outcomes; developing and proposing strategies to help meet person-centered treatment goals; assisting the patient in locating or navigating recovery support services; each additional 30 minutes of services (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to each primary code). Note: Effective January 1, 2025, HCPCS codes G2070 through G2072 will be deleted because the buprenorphine implant (Probuphine ®) reflected within these bundled payments was discontinued on October 19, 2020. There are currently no other generic equivalent available for buprenorphine implants