Practitioner Claims submission – A/B MAC (B)

40 - Practitioner Claims submission – A/B MAC (B) (Rev. 13147; Issued: 03-28-25; Effective: 01-01-25; Implementation: 03-25-25) Beginning January 1, 2020, claims for OTP services are submitted using the 837P transaction to transmit health care claims electronically, or using the CMS-1500 (the paper version of the 837P). Beginning January 1, 2021, OTPs may apply on the Medicare Enrollment Application for Institutional Providers (CMS-855A) or through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS)(837I) when they enroll in the Medicare Program. These providers will submit claims using the CMS-1450. HCPCS codes G2067-G2069, G2073-G2077, G0137, and G0533 cover episodes of care of 7 continuous days and cannot be billed for the same patient more than once per 7 continuous day period. HCPCS codes G2076-G2080, G0137, and G0534-G0536 are add-on codes that are billed in addition to one of the base bundle codes described by HCPCS codes G2067-G2069, G2073-G2077, and G0533. Consistent with FDA labeling, HCPCS codes G2069 and G2073 should not be used more than once every 4 weeks. HCPCS codes G2078 and G2079 may be billed in multiple units, up to 3 in one month (in addition to the base bundle code). HCPCS codes G2215, G2216, and G0532 are limited to being billed once every 30 days, however, exceptions to this limit are allowed in the case where the beneficiary overdoses and uses the initial supply of naloxone or nalmefene dispensed by the OTP to the extent that it is medically reasonable and necessary to furnish additional naloxone or nalmefene. If an additional supply of naloxone or nalmefene is needed within 30 days of the original supply being provided, OTPs must document in the medical record the reason for the exception. HCPCS code G2216 (injectable naloxone) is contractor- priced for CY 2021. Patients may be appropriately given OUD services at more than one OTP within a 7 day period in certain limited clinical situations, such as for guest dosing or when a patient transfers care between OTPs. Each of the involved OTPs may bill the appropriate HCPCS codes for the services provided to the patient, but both OTPs must maintain sufficient medical record documentation to reflect the clinical situation and services provided. 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.