On January 1, 2020, CMS implemented the Medicare Opioid Treatment Program (OTP) for Part B beneficiaries to address opioid misuse. The program provides medication-assisted treatment (MAT) benefits for people diagnosed with an opioid use disorder (OUD).

Covered benefits include:

  • U.S. Food and Drug Administration-approved opioid (MAT) medications, including agonist (causes an action) and antagonist (blocks an action) medications
  • Individual and group substance use counseling
  • Toxicity testing
  • Intake activities and periodic assessments

Provider Billing

OTP providers must be fully certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), accredited by a SAMHSA-approved entity and enrolled in the Medicare OTP before they can bill Medicare for OTP services. Click here for more information about SAMSHA certification, or visit the SAMSHA Opioid Treatment Program Directory to find a local accredited OTP provider.

  • Medicare will be the primary insurance for dual-eligible beneficiaries (eligible for both Medicare and Medicaid benefits).
  • To report MAT services, the appropriate Healthcare Common Procedure Coding System (HCPCS) code ranges G2067–G2075 or add-on codes G2076–G2080 must be used. Only providers who are authorized under state law to furnish such treatments will be reimbursed. CMS has provided a Medicare Billing and Payment Fact Sheet to assist providers.
  • The Place of Service (POS) code 58 (Nonresidential Opioid Treatment Facility) is the only service code that can be reported on OTP claims.
  • The Locality Key and Locality Adjusted Rates PDFs located on CMS’ website enable providers to determine what their adjusted payment rate is based on their geographical location.

Office-based physicians (POS 11) providing OUD services may report HCPCS codes G2086– G2088 and are paid under the physician fee schedule. Visit CMS’ Frequently Asked Questions for further details.

With the focus on expanding covered treatment options and easier access to OTP services, Medicare and OTPs are a leading force in the fight against the opioid crisis. For more information, reach out to your BKD Trusted Advisor™ or use the Contact Us form below.

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