Opioid Treatment Program (OTP)

Providers are in the best position to identify and manage potential opioid overutilization. The CMS finalized new opioid policies for Medicare drug plans starting on January 1, 2019. The new policies include improved safety alerts when opioid prescriptions are dispensed at the pharmacy and drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs.

To view how to enroll in the Opioid Treatment Program, go to the Enrollment page.

Initial Preventative Physical Exam (IPPE)

During the IPPE, review the patient's medical and social history. Medicare would like to emphasize that review of opioid use is a routine component of this element, including Opioid Use Disorders (OUDs). If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.):

  • Review potential risk factors for depression and other mood disorders
  • Review functional ability and level of safety
  • Measurement of height, weight, body mass index (BMI), and visual acuity screening
  • End-of-life planning (upon agreement of the individual)
  • Education, counseling and referral based on the review of previous 5 components
  • Education, counseling and referral for other preventive services, including a brief written plan such as a checklist

Annual Wellness Visit

During initial or subsequent AWVs, update medical and family history. Medicare would like to include opioid use in the ‘Review of Medical and Family History' element of the AWV. Providers are encouraged to pay close attention to opioid use during this element of the AWV. If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.

Centers for Disease Control (CDC)

The CDC has resources to help providers apply the "Guideline for Prescribing Opioids for Chronic Pain."

Access the below documents from the "No Shortcuts to Safer Opioids Prescribing: CDC Commentary" section of the CMS MLN Connects - May 23, 2019

  • Pocket Guide: Tapering Opioids for Chronic Pain
    • Quick-reference tool for when and how to taper and important considerations for safe and effective care
  • CDC Opioid Prescribing Guideline Mobile App
    • Apply recommendations in clinical practice, including a morphine milligram equivalent calculator, key recommendations, motivational interviewing techniques, resources, and glossary
  • Applying CDC's Guideline for Prescribing Opioids Series
    • Interactive, web-based training featuring 11 self-paced learning modules with case-based content, knowledge checks, and integrated resources

OTP Coverage

OTP started in 2020 to address beneficiary's substance use disorder that occurs when the use of alcohol or drugs (like opioids) cause health problems or disability. Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act was outlined to address the misuse.

Weekly Opioid Treatment Programs provide medication-assisted treatment for beneficiaries diagnosed with Opioid Use Disorder (OUD):

  • Must be certified and accredited by Substance Abuse and Mental Health Services Administration (SAMHSA)
  • For certification, OTPs must comply with all pertinent regulations and state laws, including DEA or Drug Enforcement Administration regulations
  • Specially enrolled and approved provider only bills OTP and cannot bill other Medicare non-OTP services

OUD weekly treatment services include:

  • FDA-approved opioid medications and if applicable, administering or dispensing of those medications
  • Important counseling piece for substance use that include both therapies, individual and group
  • Toxicology testing may include both definitive and presumptive
  • Any intake activities and assessing patient periodically

Telehealth:

  • CMS allows group or individual counseling with two-way interactive audio and video communication
  • During public health emergency (PHE), therapy, counseling, and assessments may be furnished by telephone only, if all other requirements met
  • Place of service = as if furnished in person and to indicate telehealth, append modifier 95
  • Modifier 95 - counseling and therapy provided using audio-video telecommunications
  • Modifier FQ - counseling and therapy provided using audio-only telecommunications

After the COVID-19 public health emergency (PHE) ends, CMS will allow audio-only interactions (like telephone calls) when audio-video communication NOT available to patient or can't agree to two-way audio-video communication

  • HCPCS G2080 can be used for counseling and therapy via audio-video appending either modifier 95 or FQ

Billing

  • Special place of service (POS) 58 billing once per week
  • No date span needed; bill first date treating beneficiary or standard weekly billing cycle
  • OTP not considered physician services without technical or professional code split
  • Item 24J - Do not bill individual provider NPI - leave blank or bill OTP group NPI from Item 33
  • Bill within 12-month timely filing after date of service
  • Copayment waived
  • Nine HCPCS G-codes (G2067-G2075) and if needed, 5 intensity add-on G-codes (G2076-G2080)
  • Weekly drug treatments bundle for seven-day contiguous period with administering buprenorphine (oral, injectable, or implantable), other medications (naltrexone), methadone and non-drugs
  • Beneficiary may see more than one OTP provider for weekly payment
    • E.g., OTP clinician and separate licensed Mental Health provider in same week
    • May be treated at another OTP (out of town) called "guest dosing"
  • Need Prescribing practitioner referral name (Item 17) and NPI # (17B)
  • No limit on length of time beneficiary needs OTP, as long as in treatment and receiving services
  • No special billing diagnosis(es)
  • 2021 HCPCS added: nasal (G2215) and injectable (G2216) naloxone
  • 2022 established higher dose for Naloxone hydrochloride nasal spray, due to fentanyl overdose increase
    • New HCPCS G1028 - take-home supply of nasal naloxone; 2-pack of 8mg per 0.1 mL nasal spray
    • Original HCPCS G2215 - take-home supply of nasal naloxone; 2-pack of 4mg per 0.1 mL nasal spray

Documentation

  • https://www.ecfr.gov/current/title-21/chapter-II/part-1304?toc=1 Part 1304.03
    • Practitioners must keep records and inventories on all controlled substances
    • DEA record-keeping requirements for buprenorphine treatment beyond Schedule III
  • Upon request, provide sufficient documentation to reflect clinical situation and services provided
  • Check Noridian's Browse by Topic, under Documentation Requirements

Payment

OTP fees have own pricing, under Noridian's Fees and News, Fee Schedules and adjusted by geographic state and locality (by medication administered) and include:

  • Drug costs = national average drug acquisition cost when Average Sales Pricing (ASP) not reported
  • Non-drug costs = bundled delivery of counseling, exam, therapy, testing, assessments, intake activities, dispense and administer medications, etc.

Resources

 

Last Updated Wed, 02 Mar 2022 16:39:13 +0000