Opioids and coding: An important new program to meet funding needs for treatment

Jennifer SwindleCoding

When you think of America’s opioid crisis, your thoughts probably don’t quickly turn to medical codes. And yet, the fact is that when medical crises arise, code changes are made to accurately capture and support needed services. Opioid addiction, with millions of people affected and horrendous loss of life as well as broken lives, is certainly such a crisis, perhaps the biggest public health challenge of the 21st century. In order to treat it, you need to get paid for it. The SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recover and Treatment for Patients and Communities) Act, which was enacted on Oct. 24, 2018, established a benefit category to begin on or after Jan. 1, 2020.

Final SUPPORT Act regulations are due soon from the Centers for Medicare and Medicaid Services, and there are many elements to it from a coding and billing perspective. A proposed rule published in July 2019 expanded the types and places of service for addiction treatment and defines a new Opioid Treatment Programs designation. Some services had previously been allowed in physicians’ offices and acute-care facilities, but the new law allows for other facilities to use evidence-based care, including methadone, for opioid addictions. These proposed changes are a new CMS Part B benefit; the statute defines who would be covered, as well as the scope and frequency of the services, and there will be additional revenues available to support these services.

There are three Healthcare Common Procedure Coding System (HCPCS) procedure codes being created to report services for opioid use disorder. Office-based treatment, which includes the development of a treatment plan, care coordination, individual and/or group therapy and counseling, is based on the initial month and subsequent months and has time requirements. CMS is proposing that the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate. The codes are as follows:

  • GYYY1 is office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy, and group therapy and counseling. This must include at least 70 minutes of therapy in the first calendar month.
  • GYYY2 would then cover the same services in subsequent months and has a time component of at least 60 minutes.
  • GYYY3 is an add-on code for each additional 30 minutes and begins after 120 minutes and can be reported with either of the above services.

A new place of service has been proposed for Opioid Treatment Programs, since they will potentially be a covered location and then additional new G codes have been proposed for these services. The G codes vary, but are based on a weekly bundle which includes all services for the week and codes vary based on the medication being utilized for treatment; there will be a drug component and a non-drug component payment amount. Some examples (not an all-inclusive list) would include:

  • GXXX1: Medication-assisted treatment (methadone); a 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).
  • GXXX2: 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).

There also is a proposed add-on code for additional time that may need to be captured.

While this is a proposed rule at this time and has not been finalized, it is always recommended to monitor closely the changes that may be coming and the impact they may have either on an individual organization or on referrals of patients who can receive help for this debilitating disease in a new setting previously not approved for payment. Certainly the healthcare industry realizes the significance of getting this crisis managed and helping all those who suffer from opioid abuse and dependence. Allowing for payment for additional services may help patients receive the help they need.