OTP Provisions in 2020 Physician Fee Schedule

CMS finalized provisions for the nation’s opioid treatment programs (OTPs) in the 2020 Physician Fee Schedule regulation that the agency released on Nov. 1.

This NABH Analysis provides a summary of those provisions, which provide for the treatment of opioid use disorders (OUDs) with new bundled service codes for OTPs, and for telehealth and opioid use treatment services in office-based settings. The final rule will be published in the Federal Register on Nov. 15.

The regulations implement requirements that were included in last year’s Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities (SUPPORT) Act. NABH is pleased that the final rule addressed the following issues that NABH mentioned in its comment letter on Sept. 28:

  • CMS raised the non-drug bundle to 161.71, which aligns with NABH’s valuation. We used a building block methodology to demonstrate that the proposed non-drug bundle, based on the CMS PFS rates, was undervalued by 31-48 percent.
  • We also identified a range of indirect and direct services routinely performed by OTPs that CMS included in the final bundle.
  • NABH advocated for the elimination of the partial bundle and recommended a more gradual overall implementation of elements of the proposed rule. In the final rule, CMS temporarily eliminated the partial episode of care with the intent to engage in future rulemaking to more gradually phase in their bundled approach.
  • Comments and data were provided to CMS reflecting potential destabilization of the workforce relevant to the proposed service requirements. CMS addressed these issues through deference to state laws and scopes of service provisions, and a reduction of the number of services needed to bill the bundle.
  • In explanatory text, CMS made note of the NABH recommendation for a rural add-on rate of 17 percent and indicated it may be considered in future rulemaking to incentivize rural care.
  • NABH recommended consideration to permanently set a zero co-pay, and CMS indicated the intent to address the issue in future rulemaking.
  • We advocated to remove OTPs from the high-risk category. CMS finalized a compromise proposal that moves OTPs that have been fully and continuously certified by SAMSA since October 23, 2018 to moderate risk, while maintaining those without full and continuous certification in the high-level risk category, as they are newly-recognized Medicare providers.
  • NABH-supported telehealth codes were finalized.

Final Rule Highlights:

Opioid Treatment Programs

  • Definition of OUD Treatment Services
    • FDA-approved opioid agonist and antagonist treatment medications
    • Dispensing and administering of such medications (if applicable)
    • Substance use counseling
    • Individual and group therapy
    • Toxicology testing (both presumptive and definitive testing)
    • Intake activities
    • Periodic assessments
  • Bundled Rates/Episode of Care
    • Bundles reflect a weekly episode of care with no time limits.
    • Rates are a combination of a drug and non-drug component.
    • Full and partial episode construction was finalized to eliminate of partial episodes of care. Utilization will be monitored, intent is to create a partial bundle in the future.
    • One service must be furnished within a week to bill a weekly drug or non-drug bundle.
  • Drug component reflects drug dispensing/administration services; rates vary according to the specific drug (methadone-oral, buprenorphine-oral, buprenorphine-injection, buprenorphine-implant, naltrexone injection), and includes buprenorphine-only products.
    • Maintenance dosage and calculation for oral buprenorphine was increased from 10 mg to 16 mg daily.
    • Created an NOS code for new medications.
  • Non-drug component includes counseling, psychotherapy, toxicology testing and tracks with SAMHSA certification.
    • Does not require counseling and psychotherapy but defers to medical need and state laws relevant to scopes of practice.
    • Case/care management is not included as a bundled or add-on code. Intent to collaborate with OTPs to better understand services, with potential future rulemaking.
    • Rates were increased using building block methodology that values the services based on established Medicare PFS (non-facility) rates for similar services; the Medicare Clinical Laboratory Fee Schedule (CLFS); and state Medicaid programs.
    • Bundles include payment for presumptive and definitive drug testing, with no separate billing under CLFS. There is no add-on code in order to avoid incentive to test more frequently than needed.
  • Add-ons
    • Intake activities for new patients, including a physical examination
    • Periodic assessments during an episode of care, such as for pregnant or postpartum patients
    • Take homes for methadone/buprenorphine for up to 7 days of medication
    • Counseling 30-minutes when counseling or therapy substantially exceed the amount in the individual treatment plan

PFS Bundles for Office-based Services/Telehealth

  • Bundled Rates/Episode of Care
    • Codes for three new (monthly) OUD treatment bundles have been added to the telehealth list on a Category 1 basis for care coordination, individual and group therapy, and counseling through two-way interactive audio-video communication technology.
      • G2086, 70-minute psychotherapy, first month. Includes treatment planning, care coordination, individual and group psychotherapy and counseling
      • G2087, 60-minute psychotherapy, subsequent months. Includes care coordination individual and group psychotherapy and counseling
      • G2088, for each additional 30-minute service required beyond 120 minutes. Includes care coordination, individual and group psychotherapy, and counseling
    • To bill G2086 and G2087, one psychotherapy services must be furnished.
    • If no therapy is provided, the bundle may not be billed. Instead, existing CPT codes for care management 99484, 99492, 99493, 99494 and E/M codes may be used.
    • Psychotherapy codes 90832, 90834, 90837, 90853 may not be used by the same practitioner for the same beneficiary in same month that episode bundles are billed.
    • Rates do not include medications, as they are reimbursed under Medicare Part B or D or toxicology testing that is billed under CLFS.
    • Provider must be licensed in the jurisdiction/location of the patient.
    • The codes are not restricted to use by addiction specialists.
    • Additional telehealth services may be requested before February 10, 2020 for consideration for the following calendar year.
    • The rule notes the prior removal of geographic limitations for telehealth services for SUD or co-occurring mental health disorders.
    • The SUPPORT ACT permits services to be furnished at any originating site, including the patient’s home, and requires that no originating site facility fee is permitted when the individual’s home is the originating site.
    • OTP services are not considered physician/practitioner services, and as such may not bill these codes. Instead, services are covered through OTP bundled rates.

NABH will closely monitor and work with CMS and other stakeholders in the implementation of this benefit and provide updates to NABH members as necessary.

If you have questions, please contact Sarah Wattenberg, NABH’s director of quality and addiction services.