Special Opioid Treatment Program Billing Requirements for Hospitals, Critical

50.1 – Special Opioid Treatment Program Billing Requirements for Hospitals, Critical Access Hospitals, and Free-Standing Opioid Treatment Program Facilities (Rev. 10521; Issued: 12-16-20; Effective: 01-01-21; Implementation: 01-04-21) Medicare Part B coverage is available for hospital outpatient Opioid Treatment Program services. A. Billing Requirement Section 1861(s)(2)(HH)(jjj) of the Act requires that opioid use disorder treatment services would include the Food and Drug Administration (FDA)-approved opioid agonist and antagonist treatment medications, the dispensing and administration of such medications (if applicable), substance use disorder counseling, individual and group therapy, toxicology testing, and other items and services that the Secretary determines are appropriate. Section 1861(s)(2)(HH)(jjj) defines OTPs as those that enroll in Medicare and are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), accredited by a SAMHSA-approved entity, and meet additional conditions as the Secretary finds necessary to ensure the health and safety of individuals being furnished services under these programs and the effective and efficient furnishing of such services. Hospitals and CAHs report condition code 89 in FLs 18-28 (or electronic equivalent) to indicate the claim is for Opioid Treatment Program services. They must also report a revenue code and the charge for each individual covered service furnished. In addition, hospital outpatient departments are required to report HCPCS codes. CAHs are not required to report HCPCS code for this benefit. Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under an opioid treatment program. In addition, hospital outpatient departments are required to report HCPCS codes. Component billing assures that only those opioid treatment program services covered under §1861(s)(2)(HH)(jjj) of the Act are paid by the Medicare program. All hospitals are required to report condition code “89” in FLs 18-28 to indicate the claim is for opioid treatment program services. Hospitals use bill type 013X and CAHs use bill type 085X. The following special procedures apply: Bills must contain an acceptable revenue code. They are as follows: Revenue Code Description 0636 Drugs Requiring Detailed Coding 0900 Behavioral Health Treatment/Services 0914 Individual Therapy 0915 Group Therapy 0916 Family Therapy 0918 0919 Behavioral Health/Testing Other Behavioral Health Treatments 0940 0944 General Classification Drug Rehabilitation 0949 0953 Other Therapeutic Service Chemical Dependency (Drug and Alcohol) Hospitals other than CAHs are also required to report appropriate HCPCS codes. Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes. Do not edit for the matching of revenue code to HCPCS. NOTE: Information regarding the Form CMS-1450 form locators that correspond with these fields is found in Chapter 25 of this manual. See the ASC X12 837 Institutional Claim implementation guide for related guidelines for the electronic claim. B. Reporting of Service Units Hospitals and Free-Standing facilities report the number of times the service or procedure, as defined by the HCPCS code, was performed. NOTE: Service units are not required to be reported for drugs and biologicals (Revenue Code 250). C. Line Item Date of Service Reporting Hospitals other than CAHs are required to report line item dates of service per revenue code line for opioid treatment program claims. This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the service was provided for every occurrence. Line item dates of service are reported in FL 45 “Service Date” (MMDDYY). D. Special Requirements for Free-Standing Opioid Treatment Program Facilities Section 1833 (s)(2)(HH)(jjj))) of the Act recognizes Free-Standing Opioid Treatment Program Facilities as “providers of services” but only for furnishing Opioid Treatment Program services. Applicable provider ranges are xx9900-xx9999 billed on a claim with a type of bill 087x. Other billing requirements (except condition code “89” reporting) mentioned above for hospitals apply. E. Payment Section 1861 (s)(2)(HH)(jjj)) of the Act provides the statutory authority governing payment for opioid treatment program services provided by a hospital or free-standing facility. A/B MAC(s) (A) make payment on a fee schedule basis (see 30.8). CAH’s are paid at reasonable cost basis. The Part B deductible applies. There is no PC/TC split for OTP billing. Only one (1) provider may bill for the services of the opioid treatment program, either the facility or the practitioner, but not both. F. Data for CWF and PS&R Include revenue codes, HCPCS/CPT codes, units, and covered charges in the financial data section (fields 65a - 65j), as appropriate. Report the billed charges in field 65h, "Charges," of the CWF record. Include in the financial data portion of the PS&R UNIBILL, revenue codes, HCPCS/CPT codes, units, and charges, as appropriate. G. Medical Review The A/B MACs (A) follow medical review guidelines in Pub. 100-08, Medicare Program Integrity Manual.