Opioid Treatment Program Reimbursement
Origination Date: November 1, 2023
Last Review Date: April 1, 2026
Description
Opioid Treatment Programs (OTPs) are state and federally regulated to dispense opioid agonist treatment and provide daily supervised dosing of methadone, buprenorphine or naltrexone.
Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) will provide reimbursement for opioid treatment programs as outlined in this policy.
Reimbursement Guidelines
OTP providers may only be reimbursed using the bundled payment codes G1028, G2067 through G2080, and G2215 to G2216.
Only OTP providers are eligible for reimbursement using G0532, G0533, G1028, G2067 through G2080, and G2215 to G2216.
Place of service 58 (non-residential opioid treatment facilities) is required for all claims submitted by OTPs.
Reimbursement for bundled weekly OTP services (G0533, G2067-G2075) is limited to once per 7 days. When multiple drugs are provided to a member in the same week, the G code corresponding to the drug provided for the majority of the week should be filed.
Consistent with FDA labeling, reimbursement for:
- weekly OTP services using G2069 and G2073 is limited to once per 28 days.
- drug take home supply (G2078 and G2079) is limited to three (3) units per 28 days.
When submitting a claim for HCPCS code G0532 (take-home supply of nasal nalmefene hydrochloride, nasal spray) or G2216 (take-home supply of injectable naloxone), OTP providers must note the dosage dispensed to the member in the units field of the claim form (box 24G of the 1500), rounded to the nearest whole number (with a minimum dosage of 1mg).
Rationale
In accordance with CMS, Blue Cross NC will limit reimbursement for OTPs to the codes G0532, G0533, G1028, G2067 through G2080, and G2215 to G2216.
Following SAMHSA guidance, a maximum take-home supply of one month of medication is allowed. Therefore, Blue Cross NC will limit the add-on codes for take home supply of methadone and oral buprenorphine (G2078 and G2079) to be billed 3 times in 28 days (in addition to the weekly bundled payment code).
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.
| HCPCS Code | Description |
| G0532 | Take-home supply of nasal nalmefene HCl; 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) |
| 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) |
| 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 MOUD 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) |
| G0560 |
Safety planning interventions, each 20 minutes personally performed by the billing practitioner, including assisting the patient in the identification of the following personalized elements of a safety plan:
|
| 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 |
| 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) |
| 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) |
| 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) |
| 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) |
| 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) |
| 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) |
| 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 |
| 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 |
| 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 |
| 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 |
| G2080 | Each additional 30 minutes of counseling 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 |
| 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 |
| 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 |
Related policy
n/a
References
American Society of Addiction Medicine. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. asam-national-practice-guidelinepocketguide.pdf
Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Federal Guidelines for Opioid Treatment Programs (samhsa.gov): https://store.samhsa.gov/sites/default/files/d7/priv/pep15-fedguideotp.pdf
Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63, Full Document. HHS Publication No. (SMA) 195063FULLDOC. TIP 63: Medications for Opioid Use Disorder | SAMHSA: https://www.samhsa.gov/resource/ebp/tip-63-medications-opioid-use-disorder
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Psychiatry.org - APA Releases Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DS: https://www.psychiatry.org/news-room/news-releases/apa-releases-diagnostic-and-statistical-manual-of
History
| Date | Revision |
| 1/1/2024 | New policy developed. Medical Director approved. Notification on 11/1/2023 for effective date 1/1/2024. (ss) |
| 12/31/2024 | Added codes to Billing and Coding section: G0532, G0533, G0536, G0560. Deleted codes: G2070, G2071, G2072. Updated code definitions throughout. No change to policy intent. (tlc) |
| 1/1/2026 | Updated Application section to include Healthy Blue + Medicare (HMO-POS D-SNP). Notification on 11/1/2025 for effective date 1/1/2026. (dc) |
| 4/1/2026 | Update to code definitions. No change to policy intent. (tlc) |
Application
These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, Healthy Blue + Medicare (HMO-POS D-SNP), and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.
This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.