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KMAP BULLETIN: Updated: Medication Assisted Treatment – Opioid Treatment Programs

Date: 04/13/21

KMAP GENERAL BULLETIN 20194 (PDF)

Effective October 1, 2020 through September 30, 2025, all Medication Assisted Treatment (MAT) drugs and biological products, used for Opioid Use Disorder (OUD) will be covered. All MAT drugs and biologicals billed through the medical benefit require a diagnosis code to be considered for payment.

Medications Covered:

MAT drugs used for OUD are considered Part B drugs, per Medicare guidelines. The following drugs are covered MAT drugs for Opioid Treatment Program (OTP):

  • Buprenorphine brand products and their associated generics:
    • Buprenorphine sublingual tablets (Subutex)
    • Buprenorphine/naloxone sublingual films (Suboxone)
    • Buprenorphine/naloxone) sublingual tablets (Zubsolv)
    • Buprenorphine/naloxone buccal film (Bunavail)
    • Buprenorphine implants (Probuphine)
    • Buprenorphine extended-release injection (Sublocade)
  • Methadone
  • Naltrexone brand products and their associated generics:
    • Naltrexone tablets (Depade, Revia)
    • Naltrexone injection (Vivitrol)

Provider Information:

Collaboration and documentation between the OTP and other providers assisting with related OTP services is required to coordinate services included in codes that are a bundled service.

Opioid treatment providers are required to be enrolled in Medicare as an OTP provider. Verification of Medicare enrollment is required. Providers who are enrolled as a Medicare provider for OTP and enroll as a Medicaid provider will be exempt from the Medicaid enrollment fee. Medicaid dual eligible information can be found here.

All licensures must be in accordance with Medicare standards.

Approved Providers:

Allowed Practitioners will be those individuals employed in a licensed SUD Program as allowed by State Licensing regulations and/or standards.

Coding for MAT and Add on Codes:

The threshold for billing the codes describing weekly episodes, Healthcare Common Procedure Coding System (HCPCS) codes G2067-G2075, is the delivery of at least one service in the weekly bundle (from either the drug or non-drug component). If no drug was provided to the patient during that episode, the OTP must bill the G-code describing a weekly bundle does not include the drug (G2074) and the threshold to bill would be at least one service in the non-drug component. If a drug was provided with or without additional non-drug component services, the appropriate G-code describing the weekly bundle that includes the drug furnished may be billed.

CMS established HCPCS G-codes describing treatment with:

  • Methadone (G2067)
  • Buprenorphine oral (G2068)
  • Buprenorphine injectable (G2069)
  • Buprenorphine implants (insertion, removal, and insertion/removal) (G2070, G2071, and G2072)
  • Extended-release, injectable naltrexone (G2073)
  • Non-drug bundle (G2074) bill for services furnished during an episode of care when a medication is not administered. For example, in the case of a patient receiving injectable buprenorphine, we would expect that OTPs would bill HCPCS code G2069 for the week during which the injection was administered and you would bill HCPCS code G2074, which describes a bundle not including the drug, during any subsequent weeks when you furnish at least one non-drug service until you administer the injection again, at which time, you would bill HCPCS code G2069 again for that week.
  • Medication not otherwise specified (G2075) - Use when you give MAT services with a new opioid agonist or antagonist treatment medication approved by the Food and Drug Administration (FDA) under Section 505 of the United States Federal Food, Drug, and Cosmetic Act (FFDCA) for the treatment of OUD.

Additionally, CMS established add-on G codes for:

  • Intake activities (G2076)
  • Periodic assessments (G2077)
  • Take-home supplies of methadone (G2078) and take-home supplies of oral buprenorphine (G2079)
  • Additional counseling furnished (G2080)

Frequency of use and other billing guidelines:

  • G2067 – G2075 may not be billed more than once per 7 days
  • G2069 and G2073 may not be billed more than once every 4 weeks.
  • G2070 and G2072 may not be billed more than once every 6 months.
  • G2076 (describing intake activities) should only be billed for new patients. (No "specific" direction for this code currently).
  • G2078 or G2079 may not be billed with more than 3 units (one month take home supply). Substance Abuse and Mental Health Services Administration (SAMHSA) allows a maximum takehome supply of one month of medication; therefore, we do not expect the add-on codes describing take-home doses of methadone and oral buprenorphine to be billed any more than 3 times in one month (in addition to the weekly bundled payment).
  • G2078 (take-home supply of methadone) may only be billed with G2067 (methadone weekly episode of care).
  • G2079 (take-home supply of buprenorphine) may only be billed with G2068 (buprenorphine weekly episode of care).
  • G2080 may be billed when counseling or therapy services are furnished that substantially exceed the amount specified in the patient’s individualized treatment plan. OTPs are required to document the medical necessity for these services in the patient’s medical record.
  • Codes G2067 through G2075 may not be billed within the same 7-day period. 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.
  • G2016 G2067 or 80358 cannot be billed within the same 14 days.
  • G2067 or G2078 AND 83840 or H0020 or S0109 cannot be billed in the same week.
  • G2080 and H0004 or H0005 cannot be billed within the same week.
  • H0004 AND G2067 or G2068 or G2069 or G2070 or G2071 or G2072 or G2073 or G2074 cannot be billed within the same week.
  • H0005 or H0005 U5 AND G2067 or G2068 or G2069 or G2070 or G2071 or G2072 or G2073 or G2074 cannot be billed within the same week.
  • H0006 or H0006 U5 AND G2067 or G2068 or G2069 or G2070 or G2071 or G2072 or G2073 or G2074 cannot be billed within the same week.
  • H0015 or H0015 U5 AND G2067 or G2068 or G2069 or G2070 or G2071 or G2072 or G2073 or G2074 cannot be billed within the same week.
  • G2068 or 80348 cannot be billed within the same 14 days.
  • G2068 or G2079 AND J0571 or J0572 or J0573 or J0574 or J0575 cannot be billed within the same week. 
  • G2073 and J2315 cannot be billed within the same 4 weeks.
  • G2069 AND Q9991 or Q9992 cannot be billed within the same 4 weeks.
  • G2080 and H0004 should not be billed within the same week.
  • G2070, G2071, G2072 and J0570 cannot be billed more than 2 times within 12 months and no more than 2 billings per patient, per current FDA approval of this drug.
  • G2070 or G2072 and J0570 cannot be billed within the same 6 months
  • G2071 and G2072 cannot be billed within the same 6 months.
  • G2070 and G2071 can only be billed once within the same 12 months as G2072.
  • H0001 should not be billed by an OTP.
  • G2075 requires manual review.

Date of Service:

For the codes that describe a weekly bundle (HCPCS codes G2067-G2075), one week is defined as 7 contiguous days. OTPs may choose to apply a standard billing cycle by setting a particular day of the week to begin all episodes of care. In this case, the date of service would be the first day of the OTP’s billing cycle. If a beneficiary starts treatment at the OTP on a day that is in the middle of the OTP’s standard weekly billing cycle, the OTP may still bill the applicable code for that episode of care provided that the threshold to bill for the code has been met.

Alternatively, OTPs may choose to adopt weekly billing cycles that vary across patients. Under this approach, the initial date of service will depend upon the day of the week when the patient was first admitted to the program or when Medicare billing began. Therefore, under this approach of adopting weekly billing cycles that vary across patients, when a patient is beginning treatment or re-starting treatment after a break in treatment, the date of service would reflect the first day the patient was seen and the date of service for subsequent consecutive episodes of care would be the first day after the previous 7-day period ends.

For the codes describing add-on services (HCPCS codes G2076-G2080), the date of service should reflect the date that service was furnished; however, if the OTP has chosen to apply a standard weekly billing cycle, the date of service for codes describing add-on services may be the same as the first day in the weekly billing cycle.

Covered Place of Service Codes:

  • 58 - Non-Residential Opioid Treatment Facility - A location that provides treatment for opioid use disorder on an ambulatory basis. Services include methadone and other forms of Medication Assisted Treatment.
  • 15 - Mobile Unit - OTPs which have a Drug Enforcement Administration (DEA) approved mobile unit, will be reimbursed for delivery of Methadone to patients. A current agreement for approval to provide mobile unit service with the Drug Enforcement Agency is required. All requirements of the agreement and licensure thereof must be adhered to and are auditable.

Telehealth and transportation codes are covered codes for OTP services. Please refer to the Kansas Medicaid Telehealth and Non-Emergency Medical Transportation (NEMT) policies.

Current rules for other health insurance apply. Providers of this type of service are required to bill claims to primary insurance, if applicable.

Note: The effective date of the policy is October 1, 2020. The implementation of State policy by the KanCare managed care organizations (MCOs) may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.