welcome to new otp training! - home - medicare

Welcome to new OTP Training!Starts promptly at 1:00 pm CT / 11:00 am PTRight/left-side menu:• Call in # with access

code and audio pin• Handouts – download

– Webinar PDF only– No CEUs

• Keep questions to previous/current slide– To “all panelists”– No scenarios please

December 2019 1

Questions

Opioid Treatment Program (OTP)

Medicare Part A/BProvider Education & Enrollment

December 2019

DisclaimerThis information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website and the CMS website. The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

• Noridian Medicare Website (https://med.noridianmedicare.com)• CMS Website (https://www.cms.gov)

December 2019 3

https://med.noridianmedicare.com/

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance%20-Programs/CERT/Downloads/AppendicesMedicareFee-for-Service2016ImproperPaymentsReport.pdf

Acronymshttp://www.cms.gov/apps/acronyms

ACRONYM DESCRIPTION

CDC Centers for Disease Control & Prevention

CFR Code of Federal Regulations

EDI Electronic Data Interchange

FDA Food and Drug Administration

HHS Health & Human Services

MAT Medication-Assisted Treatment

MBI Medicare Beneficiary Identifier

MIPS Merit-Based Incentive Payment System

December 2019 4

http://www.cms.gov/apps/acronyms

Acronyms 2

http://www.cms.gov/apps/acronymsACRONYM DESCRIPTION

OUD Opioid Use Disorder

NPI National Provider Identifier

PTAN Provider Transaction Access Number

SAMHSA Substance Abuse & Mental Health Services Administration

SE Special Edition

SUPPORT Substance Use-Disorder Prevention Promoting Opioid Recovery & Treatment

December 2019 5

http://www.cms.gov/apps/acronyms

Agenda• Opioid Treatment Program (OTP) Overview• Special Medicare Enrollment • CMS-1500 Paper and Electronic

• Remittance Advice (RA)• Appeals• Noridian Medicare Portal (NMP)• Documentation• Billing, Coding and Payment Guidelines• Resources

6December 2019

General OTP Overview• Substance use disorders occur when the

use of alcohol and/or drugs (like opioids or tobacco) cause health problems or a disability

• Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act outlines national strategies to help address opioid misuse– Effective October 2018

December 2019 7

SUPPORT Overview• Effective January 1, 2020, CMS Substance Use-

Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) includes

• Special enrollment & strategies to address opioid misuse with links from the CDC, FDA & SUPPORT– https://www.congress.gov/bill/115th-congress/house-

bill/6/text– https://www.cdc.gov/media/releases/2019/s0424-advises-

misapplication-guideline-prescribing-opioids.html– https://www.fda.gov/drugs/drug-safety-and-availability/fda-

identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes

8December 2019

https://www.congress.gov/bill/115th-congress/house-bill/6/text

https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes

SAMHSA Overview• Opioid Treatment Programs provide

medication-assisted treatment for Medicare beneficiaries diagnosed with Opioid Use Disorder (OUD)

• Must be certified/accredited by SAMHSA – Comply with all state laws/regulations– Regulations enforced by Drug Enforcement

Administration (DEA)• Payers: Medicare, Medicaid, Tricare,

Private9December 2019

OTP Legislation and Benefit• Legislation alleviate nationwide opioid crisis

1. Reducing abuse and supply of opioids 2. Helping individuals recover from opioid addiction

and supporting their families3. Establishing innovative and long-term solutions

• Medicare previously and currently covers office-based opioid treatment with buprenorphine and naltrexone– Historically not covered in OTPs– New benefit expands access to care Jan. 1, 2020

10December 2019

OTP Treatment Services

• OUD treatment services provided by OTPs include:– U.S. FDA-approved opioid medications for OUD treatment– Dispensing and administering medications (if applicable) – Substance use counseling– Individual and group therapy – Toxicology testing, including presumptive/definitive testing – Intake activities– Periodic assessments

• Allow OTPs to furnish substance use counseling, group and individual – Via two-way interactive audio/video communication technology,

clinically appropriate & increase access to care

11December 2019

Special Medicare Enrollment

Overview >Enrollment >Paper/EDI >Appeals >NMP >Documentation >Billing/Payment >Resources

OTP Enrollment

• Definition of an OTP per 42 CFR 8.2• Enrolled in Medicare • Fully certified and accredited by SAMHSA

approved body

13December 2019

OTP Certification• OTP provider completes certification and

accreditation process – Meet other requirements outlined in

https://ecfr.io/Title-42/cfr8_main or 42 Code of Federal Regulation (CFR) 8

• Program may apply to SAMHSA for provisional (initial) certification– While working towards accreditation with

SAMHSA-approved accrediting body– Provisional certification temporary for one year– Provisional certification granted from state/DEA

14December 2019

https://ecfr.io/Title-42/cfr8_main

OTP Certification• OTP accreditation by SAMHSA regional

compliance officers– https://www.samhsa.gov/medication-assisted-

treatment/opioid-treatment-programs/compliance-officers

• Certification renewed annually or every three years depending on accreditation timeframe

• Apply for OTP certification at– https://www.samhsa.gov/medication-assisted-

treatment/opioid-treatment-programs/apply

15December 2019

https://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs/compliance-officers

https://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs/apply

OTP Enrollment Fact Sheet• Effective Oct 2019• 22 pages• https://www.cms.gov/

Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OTP-enrollment-factsheet-MLN6325432.PDF

16December 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OTP-enrollment-factsheet-MLN6325432.PDF

OTP Enrollment Now! • Submit application fee ($586 = 2019)

– https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/ MedicareApplicationFee.html

• Effective date cannot be earlier than SAMHSA certification date or Jan 1, 2020:1. Filing date of Medicare enrollment application

subsequently approved by Medicare contractor; or

2. Date first began furnishing services at new location

17December 2019

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareApplicationFee.html

OTP EnrollmentPaper:• 855B application

– Sections 1-6, 8, 13, 15 or 16PECOS• Select My Associates• Select Create Initial Enrollment Application• Select Organization Name• Select Clinic/Group Practice• Select Opioid Treatment Program

– EFT information will be filled out within the application

18December 2019

OTP Enrollment-Supporting Documentation

• CMS 460– Not required

• IRS Documentation• CMS 588-EFT (Electronic Funds Transfer)

– Voided check or signed bank letter• Copy of SAMHSA Certification• Organizational Chart• CMS 1561 Provider Agreement signed by

current Authorized Official (AO) or Delegated Official (DO)

19December 2019

Enrollment Resources• CMS-1561 Agreement

– https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/ CMS1561.pdf

• CMS-460 PAR Agreement– https://www.cms.gov/Medicare/CMS-Forms/CMS-

Forms/downloads/cms460.pdf• CMS-588 EFT Authorization

– https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf

• SAMHSA Programs– https://www.samhsa.gov/

• CMS-855B Enrollment Application– https://www.cms.gov/Medicare/CMS-Forms/CMS-

Forms/Downloads/cms855b.pdf20December 2019

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms460.pdf

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf



https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf

CMS-1500 Paper or Electronic Equivalent


CMS-1500 Form/Format• Items 11b, 14, 16, 18,

19, 24a– Once format selected, do

not intermix – 6 or 8 digit format– Date of birth must be 8

digit only – Items 12 and 31 exempt

• Items 3, 9b, 11a– 8 digit birth date =

MMDDCCYY

December 2019 22

Item 1 – Type of Insurance

Paper: Electronic: Loop Segment Description2000B SBR09 Medicare

Indicator =MB

December 2019 23

•Check “X” under Medicare

Item 1a – Insured’s ID Number

Paper: Electronic: Loop Segment Description

2010BA NM109 Subscriber Identifier

December 2019 24

•Patient’s NEW Medicare MBI # from Medicare card

1EG4-TE5-MK72

Item 2 – Patient’s Name


2010BA

NM103 SubscriberLast Name

NM104 Subscriber First Name

NM105 Subscriber Middle Name

December 2019 25

•Enter patient’s name exactly as Medicare card

Item 3 – Patient’s DOB & Sex


2010BA

DMG02 Subscriber Birth Date

DMG03 Subscriber Gender

December 2019 26

•Patient’s eight-digit birth date in CCYY/MM/DD format •Indicate Male or Female

Item 4 – Insured’s Name


2330A

NM103 Other Insured Last Name

NM104 Other Insured First Name

NM105 Other Insured Middle Name

NM107 Other InsuredSuffix (Jr., Sr.)

December 2019 27

•Leave BLANK•Item used only if Medicare is Secondary Payer (MSP)

Item 5 – Patient’s Address/PhonePaper: Electronic:

Loop Segment Description

2010BA

N301 Subscriber Address Line 1

N302 Subscriber Address Line 2

N401 Subscriber City Name

N402 Subscriber State Code

N403 Subscriber Zip Code

December 2019 28

Item 6 – Patient’s Relationship to Insured

Paper: Electronic:Loop Segment Description2000B SBR02 Individual

RelationshipCode

2320 SBR02 IndividualRelationship

Code (MSP)

December 2019 29

•Leave Blank if Medicare is Primary

Item 7 – Insured’s Address/PhonePaper: Electronic:


2330A

N301 Other Subscriber Address Line 1

N302 Other Subscriber Address Line 2

N401 Other Subscriber City Name

N402 Other Subscriber State Code

N403 Other Subscriber Zip Code

December 2019 30

•Item only used for Medicare Secondary Payer (MSP) information•Only complete if Items 4,6 and 11 completed

Item 8 – Patient’s Marital, Employment or Student StatusPaper: Electronic:

Loop Segment DescriptionNot

MappedNot

MappedNot

Mapped

December 2019 31

•Check appropriate box for patient’s marital status and whether employed or student

Item 9 – Medigap Benefits

Paper: Electronic:Loop Segment Description

2330A

NM103 Other Insured Last Name

NM104 Other Insured First Name

NM105 Other Insured Middle Name

NM107 Other Insured Suffix (Jr., Sr.)

December 2019 32

•If no Medigap supplemental to Medicare benefits•Leave items 9a – 9d blank

Item 10a through 10c – Condition Relationship


2300

CLM11-1 Related Causes Code

CLM11-2 Additional Related Causes Code

December 2019 33

•Check “Yes” or “No” to indicate whether applies

Item 10d – Reserved for Local Use

Paper: Electronic: Loop Segment DescriptionNot

NeededNot

NeededAutomatic Crossover

December 2019 34

•Leave Blank – Not required by Noridian

Item 11 through 11c – Insured’s Policy Group or FECA NumberPaper: Electronic:

Loop Segment Description2320 SBR03 Insured’s Group

or Policy Number

December 2019 35

• Item 11 usually NONE with 11a-11c blank • Pertains to Medicare as secondary payer

Item 11d – Another Health Benefit Plan

Paper: Electronic: Loop Segment

Leave Blank Not Used by Medicare

December 2019 36

•Leave Blank - Not required for Medicare claims

Item 12 – Patient or Authorized Person’s Signature

Paper: Electronic:Loop Segment Description2300 CLM09 Release of

Information Code

December 2019 37

•Authorizes release of medical information necessary to process claim

•Name or Signature on File or SOF•Do not leave blank•Electronically indicated by “I” or “Y”

Item 14 – Date of Current Illness/Injury/Pregnancy


2300 DTP03

439 = AccidentDate

431= Onset of Current Illness

or Injury

2300 or 2400 DTP03

454= Initial Treatment Date

December 2019 39

•Date Format in CCYYMMDD

Item 15 – Same or Similar Illness

Paper: Electronic:Loop Segment

Leave Blank Not Used By Medicare

December 2019 40

•Leave blank. Not used by Medicare.

Item 16 – Dates Patient Unable to Work in Current Occupation


2300 DTP03

360 = Initial Disability

Period Start

361= Initial Disability

Period End

December 2019 41

•Indicates employment-related insurance coverage

Item 17 –Referring or Ordering Physician Name


2310Aor

2420F

NM103 DN= Referring Provider Last

NameNM104 Referring

Provider First Name

2420E

NM103 DK= Ordering Provider Last

NameNM104 Ordering

Provider First Name

December 2019 42

•Leave blank or enter qualifier DN or DK

Item 17a & 17b – Referring/Ordering Physician & NPI

Paper: Electronic: Loop Segment Description2310A

Or 2420F

NM109 DN= Referring Provider

Primary ID2420E NM109 DK= Ordering

Provider Primary ID

2310D NM109 DQ = Supervising

provider Primary ID

December 2019 43

Item 17a= Leave Blank

Item 17b=NPI of referring/ordering or supervising physician-name must be in PECOS system

Item 18 – Hospitalization Dates Related to Current Services


2300 DTP03

435= Related HospitalizationAdmission Date

096= Related Hospitalization Discharge Date

December 2019 44

• Leave blank as not used in OTP billing

Item 19 – Narrative Field

Paper: Electronic: Service Loop Segment Description

Medication not otherwise

specified

2300 or

2400

DTP03 Drug name, dosage, invoice not reflected in other G codes

December 2019 45

• OTP only needs Item 19 narrative completed when G2075 (medication not otherwise specified) with drug name, dosage, strength, invoice cost with shipping

Item 20 – Outside Lab Charges


2400

PS101 Purchased Service

Reference Number

PS102 Purchased Service Charge Amount

December 2019 46

•Mark No as outside lab not OTP involved•Required when billing for diagnostic tests subject to purchase price limitations

X

Item 21 – Patient’s Diagnosis


2300

HI01-02 ABK= Principal Diagnosis

CodeHI02-02 thru 12

ABF= Diagnosis

Code

December 2019 47

•Diagnoses entered in priority order•Use valid ICD-10-CM diagnosis(es)•Ensure ICD indicator is completed

Item 22 – Medicaid Resubmission



December 2019 48

•Leave Blank. Not required by Medicare.

Item 23 – Prior Authorization NumberPaper: Electronic:


2300 or

2400

REF02 G1 = Prior Authorization

Number

X4 = Clinical Laboratory

Improvement (CLIA) Number

2300 REF02 LX = Investigational

Device Exemption (IDE) Number

1J = Care Plan Oversight Number

December 2019 49

• Leave blank as OTP does not need

Item 24A – Date of Service


2400

DTP01 472= Service Qualifier

DTP02 D8= Date Format that will appear in DTP03

DTP03 Date forEach

Procedure

December 2019 50

•Date span billing must be consecutive days•If not, bill each service on separate lines

01 15 20 01 15 20

Item 24B – Place of Service

Paper: Electronic:Loop Segment Description2300 CLM05-1 Place of

Service Code2400 SV105 Place of

Service Code(only if

different than CLM05-1)

• Enter only one place of service (POS) code• 58 (non-residential outpatient facility)

58

Item 24C – EMG



December 2019 52


Item 24D – Procedures, Services


2400

SV101-2 Procedure Code

SV101-3 Procedure Modifier 1


SV101-5 ProcedureModifier 3


December 2019 53

G2079

Item 24E – Diagnosis LinkPaper: Electronic:


2400

SV107-1 1st Diagnosis Code Pointer

SV107-2 2nd Diagnosis Code Pointer

SV107-3 3rd Diagnosis Code Pointer

SV107-4 4th Diagnosis Code Pointer

December 2019 54

•Link only one diagnosis letter (A-L) from Item 21•If multiples, link primary

A

Item 24F - Charges

Paper: Electronic: Loop Segment Description2400 SV102 Line Item

Charge Amount

December 2019 55

•Enter charge for each service•Negative dollar amounts not allowed•No dollar signs, decimals, dashes, commas or lines

Item 24G – Days or Units


2400

SV103 UN= UnitMJ= Minutes

SV104 Service Unit Count

December 2019 56

•Enter number of days or units

Item 24H & 24I

Paper: ElectronicLoop Segment

Leave Blank Not Used By Medicare

December 2019 57


Item 24J – Rendering Provider NPI

Paper: Electronic: Loop Segment Description2310B

or 2420A

NM109 RenderingProvider Identifier

December 2019 58

Item 25 – Federal Tax ID


2010AA

REF01 EIN= Employers

Identification Number

SSN= Social Security Number

REF02 Billing Provider Tax ID Number

or Social Security Number

December 2019 59

•Description (EIN or SSN) specified to match provider’s Medicare file

Item 26 – Patient Account Number

Paper: Electronic: Loop Segment Description2300 CLM01 Patient

Control Number

December 2019 60

•OPTIONAL internal account number from provider’s office (ex. Patient’s Chart Number)

Item 27 – Accept Assignment?


2300 CLM07

Assignment or Plan Participation

Code

A= Assigned

B= Assignment Accepted on Clinical Lab

Services Only

C= Not Assigned

December 2019 61

A = Payment to ProviderC = Payment to Beneficiary

Item 28 – Total Charges

Paper: Electronic: Loop Segment Description2300 CLM02 Total Claim

Charge Amount

December 2019 62

Item 29 – Amount Paid


2300

AMT01 F5= Patient Paid Amount

QualifierAMT02 Patient Paid

Amount

December 2019 63

•Leave blank-only when patient pays•If any dollar amount entered, part or all of the payment goes directly to the patient, even if participating provider

Item 30 – Balance Due

Paper: Electronic:

December 2019 64

Loop SegmentLeave Blank Not Used By

Medicare


Item 31 – Signature of Provider

Paper: Electronic:Loop Segment Description2300 CLM06 Physician

Signature Indicator

December 2019 65

Item 32 – Service Facility Location


2310C

NM101 77= Service Location

NM102 2= Non-Person Entity

NM103 Facility NameN301 Facility

AddressN401 Facility CityN402 Facility StateN403 Facility Zip

Code

December 2019 66

Item 32a– NPI of Service Facility

Paper: Electronic: Loop Segment Description2310C NM109 Facility

Primary Identifier

December 2019 67

•Enter NPI of Service Facility•Mostly same as Item 33/33B

•Item 32B (shaded gray) not recognized by Medicare

Item 33 – Billing Provider Location


2010AA

NM103 Provider Last or Organization Name

NM104 Provider First Name

NM105 Provider Middle Name

N301 Provider Address

N401 Provider City

N402 Provider State

N403 Provider Zip Code

PER04 Telephone Number

December 2019 68

Item 33a – Billing Provider NPI


2010AA NM109 Provider Identifier

December 2019 69

Successful Paper Completion Tips• Use official, red drop-out

ink CMS-1500 form• Black ink only• Omit extraneous data• No white out/correction

tape/scribbling over• No handwritten corrections• No highlighting• If handwriting claims, use

block uppercase letters and numbers

• No smudges/discolorations • No post-it notes attached• Do not submit zero

charges (except MIPS)• No slashed zeros• No staples• Fold claims in envelope

with ‘Headspace’• 10 or 12 point font with

preferred “Courier New”

70December 2019

Claim Rejections• Rejected claim or MA130 denial• No denial remittance sent to provider

• Receive Notice of Determination (NOD) letter • No appeal or reopening rights

• Must resubmit claim with missing information (as if new claim)

• Do not indicate corrected claim

December 2019 71

RHC/FQHC Billing• Rural Health Clinics (RHCs) and Federally

Qualified Health Centers (FQHCs)– Must be fully enrolled through SAMHSA– OTP do not affect other services – Intensive outpatient (IOP) not involved

• Submit OTP services to Medicare Administrative Contractors (MACs) on CMS-1500 or 837P

• No UB-04 or CMS-1450 billing

December 2019 72

• Standard Payment Method only– Must be fully enrolled through SAMHSA– OTP do not affect other services

• Submit OTP professional services to Medicare Administrative Contractors (MACs) on 837P or CMS-1500

• No UB-04 or CMS-1450 billing

December 2019 73

Critical Access Hospital (CAH) Billing

Electronic Data Interchange Support Services (EDISS) Contacts

December 2019 74

EDISS Contact InformationHours of Operation(your time zone) 8 a.m. to 7 p.m. CT

Phone JF: 877-908-8431JE: 855-609-9960

Fax 701-277-7850Email [email protected]

Mailing AddressEDI Support ServicesPO Box 6729Fargo, ND 58108-6729

Website http://www.edissweb.com

mailto:[email protected]

http://www.edissweb.com/

Remittance Advice (RA)

• Payment/adjustment notice sent to providers from insurance contractors

• Explains reimbursement decisions, payments, denials and claim adjustments

• For more information, see Browse By Topic– JE

https://med.noridianmedicare.com/web/jeb/topics/ra– JF

https://med.noridianmedicare.com/web/jfb/topics/ra

December 2019 75

https://med.noridianmedicare.com/web/jeb/topics/ra

https://med.noridianmedicare.com/web/jfb/topics/ra

Appeals


A/B Noridian Appeals Webpage• Noridian webpage

– https://med.noridianmedicare.com• Jurisdiction E/F; Medicare Part A/B• Browse By Topic – Appeals

• 5 levels of appeals with forms, tutorials, calculators, documentation requirements

77December 2019

https://med.noridianmedicare.com/

Portal Appeal Submission

78December 2019

Noridian Medicare Portal (NMP)

Overview >Enrollment >Paper/EDI >Appeals >NMP >Documentation >Coding/Payment >Resources

Utilize IVR or NMP • Two ways to access beneficiary information:

– Interactive Voice Response (IVR) or the Noridian Medicare Portal (NMP)

– Both need authentication • IVR guide includes availability, call-in tips, call

flow, authentication details, IVR guide & resources – JF

https://med.noridianmedicare.com/web/jfb/contact/ivr#guideflowchart

– JE https://med.noridianmedicare.com/web/jeb/contact/ivr

December 2019 80

https://med.noridianmedicare.com/web/jfb/contact/ivr#guideflowchart

https://med.noridianmedicare.com/web/jeb/contact/ivr

Registration• https://www.noridianmedicareportal.com/• Free and secure, internet-based portal • Access beneficiary information, claims,

remittance advices and financial information

• Registration Guide on website– Browse By Topic/Noridian Medicare Portal

December 2019 81

http://www.noridianmedicareportal.com/

Information You Will Need• NPI, PTAN, TIN, Trading Partner ID

– A/B Providers obtain Trading Partner ID from EDISS Connect

• https://connect.edissweb.com• http://www.edissweb.com

• Check number and amount (Provider Administrators)– Obtain from IVR

• Jurisdiction E: 855-609-9960• Jurisdiction F: 877-908-8431

December 2019 82

https://connect.edissweb.com/

http://www.edissweb.com/

Steps of Registration• 7 Steps to Registration• Name, Phone Number, Email Address

– Create Username and Password• Account Sharing is not allowed• Enroll in Multi-Factor Authentication (MFA)

December 2019 83

Hours of Availability

December 2019 84

Jurisdiction A Jurisdiction DJurisdiction E

Part AJurisdiction E

Part BJurisdiction F

Part AJurisdiction F

Part B

Hours of Availability:Monday - Friday

6 a.m. - 7 p.m. ET 6 a.m. - 8 p.m. CT 4 a.m. - 7 p.m. PT

California4 a.m. - 7 p.m. PT

Nevada and Hawaii4 a.m. - 9 p.m. PT

6 a.m. - 8 p.m. CT 6 a.m. - 8 p.m. CT

Hours of Availability:Saturday

6 a.m. - 3 p.m. ET 7 a.m. - 3 p.m. CT 4 a.m. - 2 p.m. PT

California4 a.m. - 7 p.m. PT

Nevada and Hawaii4 a.m. - 7 p.m. PT

6 a.m. - 4 p.m. CT 7 a.m. - 5 p.m. CT

Available Functions• Eligibility and MBI Lookup Tool• Claim Status

– Self-Service Reopenings (Part B Only)– Additional Documentation Request and Submission– Comprehensive Error Rate Testing (CERT) Inquiry

• Financial– 1099 Inquiry

• Appeals Status and Submission • Remittance Advices

– Claim-Specific Remittance Advices– Full Remittance Advices

• Provider Enrollment• Message Center

December 2019 85

Eligibility• Offers the following information

– Effective and Termination Dates– Part B Deductible – Part D Enrollment – Healthcare Maintenance Organization (HMO)– Medicare Secondary Payer (MSP)– Home Health and Hospice– Inpatient Stays– End Stage Renal Disease (ESRD)– Preventive Services– Medicare Diabetes Prevention Program (MDPP)

December 2019 86

Medicare Beneficiary Identifier (MBI) Lookup Inquiry

• Use to obtain MBI if unable to from patient• January 1, 2020

– Claims with MBI only accepted• Patient SSN needed for inquiry

– Ensure patient’s Social Security Number (SSN) used which may differ from Health Insurance Claim Number (HICN), if benefits under spouse or other family member

December 2019 87

Claim Status Inquiry• Check status of submitted claims• Included in Claim Status

– Self Service Reopenings (Part B Only)– Medical Review Comments– Related Claim Details– Expanded Denial Details– Additional Documentation Request (ADR)

Submission and Status– CERT Inquiry

December 2019 88

Appeals

• Submit appeal for denied claims– Upload documentation to support appeal

• Check status of all submitted appeals• Notification letter of denial or partial

denials available in portal

December 2019 89

Website

December 2019 90

NMP Webpage

December 2019 91

Contacts• Jurisdiction E

– Phone: 855-609-9960• Functionality: Customer Service• Accounts: User Security

• Jurisdiction F– Phone: 877-908-8431

• Functionality: Customer Service• Accounts: User Security

December 2019 92

Documentation


Documentation Requirements• Under Electronic Code of Federal Regulations

(CFR), Part 1304.03 titled Persons required to keep records and file reports at https://www.ecfr.gov/cgi-bin/ECFR?page=browse– Practitioners must keep records/inventories of all

controlled substances– Dispensed including approved buprenorphine – DEA record keeping requirements for buprenorphine

treatment go beyond Schedule III • Patients may return to prescribing physician after

receiving approved buprenorphine product– Physician can monitor while prescription taken– However, physicians should not store and dispense

controlled substances from pharmacy prescriptions

December 2019 94

https://www.ecfr.gov/cgi-bin/ECFR?page=browse

Office of Inspector General (OIG)• Opioid manufacturer agrees to $225 million

global resolution of Criminal and Civil Investigations per Department of Justice (DOJ) and OIG finding – June 5, 2019 – Company admits illegal conduct promoting this

powerful Opioid painkiller Subsys (sublingual fentanyl spray)

– Violation of False Claims Act via payment of kickbacks and other unlawful marketing practices

December 2019 95

Billing, Coding & Payment Guidelines


Who Can Bill?

• Only approved OTPs may bill specific G code services– No other provider can bill for OTP

• OTPs cannot bill Medicare for non-OTP services

December 2019 97

Special Place of Service (POS) 58

• 58 Non-residential Opioid Treatment Facility– Location providing treatment for opioid use

disorder on ambulatory basis– Services include methadone and other forms of

Medication Assisted Treatment (MAT) • Effective January 1, 2020

December 2019 98

Billing OTP Weekly Treatments

• Codes describing OTP treatment services not considered physicians’ services and paid outside Physician Fee Schedule (PFS)

• Assigned flat dollar payment amounts • CMS adopted OUD treatment services

coding structure varied by medication administered

• 9 G-codes (G2067-G2075) and 5 intensity add-on G-codes (G2076-G2080)

99December 2019

Billing OTP Weekly Treatments 2

• Weekly (7-day contiguous period) that bundles described treatment with– Methadone– Oral buprenorphine, injectable buprenorphine,

buprenorphine implants (insertion, removal, and insertion/removal)

– Extended-release injectable naltrexone– Medication not otherwise specified– Non-drug bundle

• CMS Billing & Payment page for more information– https://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/Opioid-Treatment-Program/Billing-Payment.html

100December 2019

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program/Billing-Payment.html

CY 2020 Payment Rates• Beneficiary copayment waived; deductible applies• CMS 1715-F Final Payment Rates

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program/Downloads/CY2020-OTP-Payment-Rates.pdf

• Drug costs = national average drug acquisition cost when Average Sales Pricing (ASP) not reported

• Non-drug costs = bundled delivery of counseling, exam, therapy, testing, assessments, intake activities, dispense/administer medications, etc. – Adjusted by geographic locality

101December 2019

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program/Downloads/CY2020-OTP-Payment-Rates.pdf

Billing/Pricing Explanation

• HCPCS (Special billing G code)• Descriptor (G code description)• Drug Cost (Medication type) plus• Non-Drug Cost (Intake activities from last

slide) = equals Total Cost (Medicare allowable)

December 2019 102

HCPCS Billing & PricingAll service provisions by Medicare enrolled OTP

HCPCS Descriptor Drug Cost

Non-Drug Cost

Total Cost

G2067 Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy and toxicology testing

$35.28 $172.21 $207.49

G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensingand/or administration, substance use counseling, individual and group therapy and toxicology testing if performed

$86.26 $172.21 $258.47

103December 2019

HCPCS Billing & Pricing 2


Non-Drug

Total Cost

G2069 Medication assisted treatment, buprenorphine (injectable); weekly bundle includingdispensing and/or administration, substance use counseling, individual and group therapy,and toxicology testing

$1578.64 $178.65 $1757.29

G2070 Medication assisted treatment, buprenorphine (implant insertion); weekly bundle includingdispensing and/or administration, substance use counseling, individual and group therapy,and toxicology testing if performed

$4918.98 $407.86 $5326.84

104December 2019



Non-Drug Cost

Total Cost

G2071 Medication assisted treatment, buprenorphine (implant removal);weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing

$ 0 $427.32 $427.32

G2072 Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing

$4918.98 $626.97 $5545.95

105December 2019



Non-Drug Cost

Total Cost

G2073 Medication assisted treatment, naltrexone; weekly bundle including dispensing and/oradministration, substance use counseling, individual and group therapy, and toxicology testing

$1164.02 $178.65 $1342.67

G2074 Medication assisted treatment, weekly bundle not including the drug, including substanceuse counseling, individual and group therapy, and toxicology testing

$ 0 $161.71 $161.71

106December 2019



Non-Drug Cost

Total Cost

G2075 Medication assisted treatment, medication not otherwise specified; weekly bundleincluding dispensing and/or administration, substance use counseling, individual and grouptherapy, and toxicology testing, if performed

$ ----- $ ----- $ -----

107December 2019

• Item 19 narrative/comment field must contain drug name, dosage, how administered and invoice cost

Intensity Add-On HCPCS• Next 3 slides with 5 G codes listed separately

– In addition with primary procedure• Adjust bundled payments rates if additional:

• Intake activities or periodic assessments performed

• Counseling or therapy furnished that substantially exceeds what’s specified in patient’s individualized treatment plan

• Take home dosing for methadone or oral buprenorphine provided

108December 2019

Intensity Add-on HCPCS 2


Non-Drug Cost

Total Cost

G2076 Intake activities, including initial medical exam; complete, fully documented physical evaluation and initial assessment by a program physician or a primary care physician, or authorized healthcare professional under supervision of a program physician/qualified personnel that includes preparation of a treatment plan for the patient’s short-term goals and tasks the patient must perform to complete; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho-social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel

$ 0 $179.46 $179.46

109December 2019


Non-Drug Cost

Total Cost

G2077 Periodic assessment; assessing periodically by qualified personnel to determine the mostappropriate combination of services and treatment

$ 0 $110.28 $110.28

G2078 Take-home supply of methadone; up to 7 additional day supply

$35.28 $ 0 $35.28

110December 2019

Intensity Add-On HCPCS 3


Non-Drug Cost

Total Cost

G2079 Take-home supply of buprenorphine (oral); up to 7 additional day supply

$86.26 $ 0 $86.26

G2080 Each additional 30 minutes of counseling in a week of medication assisted treatment

$ 0 $30.94 $30.94

111December 2019

Intensity Add-On HCPCS 3

Telehealth Office Monthly Services• G2086 ~ Office-based treatment for opioid use disorder,

including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month

• G2087 ~ Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month

• G2088 ~ Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)

December 2019 112

Billing Tips• Beneficiary may see:

– More than one OTP provider for weekly payment– May be treated at other OTP for “guest dosing”– OTP clinician and separate licensed Mental

Health provider in same week• To meet other drug & non-drug components

• Practitioner reflects name Item 17 - NPI 17B • No limit on length of time beneficiary

– In treatment and receive services• No special billing diagnosis(es)

December 2019 113

Billing Tips 2

• OTP codes weekly & Telehealth monthly• Threshold = one service per week• Determining when to bill add on codes

depends on original treatment plan – If above and beyond and well documented

• No date span on weekly billing – Bill first date treating beneficiary

• No technical/professional code split– One total rate based on geographic locality

December 2019 114

Resources


HHS Resource• October 10, HHS published “Guide for Clinicians

on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics”– https://www.hhs.gov/opioids/sites/default/files/2019-

10/Dosage_Reduction_Discontinuation.pdf– HHS guide provides advice to clinicians

contemplating or initiating change in opioid dosage – HHS does not recommend tapering opioids rapidly or

discontinuing suddenly; due to significant risks of opioid withdrawal, unless life-threatening issue confronts patient

116December 2019

https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf

CDC Opioid Outreach

• 11 online provider training listening module series (not all inclusive): – Recommendations from CDC – Implementing Opioid Prescribing Guidelines– Collaborative Patient-Provider Relationship

• https://www.cdc.gov/drugoverdose/training/online-training.html

117December 2019

https://www.cdc.gov/drugoverdose/training/online-training.html

Opioid Grants 2017/2018• Previously, SAMHSA granted regulations and

program-specific requirements when awarding Opioid Crisis Grants – Grants to States and territories for programs that

address opioid addiction– 21st Century Cures Act allowed SAMHSA award

$1 billion funding in 2017 and 2018 – Based on formula developed by agencies within

Department of Health and Human Services• Read full summary https://go.usa.gov/xm3E6• Read report https://go.usa.gov/xm3EF

118December 2019

https://click.connect.hhs.gov/?qs=21e7ed4686ec74ddfd87c22f777593da6f2fb4ff8005fe82b5a6f369c9cffd46971f7702753434d08e7109b4ea2146e568359bb1e5db381a

https://click.connect.hhs.gov/?qs=21e7ed4686ec74ddcb9083fac026d65c51fcf4b58c97f55b5ad7c50218a9b88f23e9695523066e441eb00c354b7c7dbdcc20f54a87349fd4

AWV/IPPE Opioid Review – SE 18004

• Review of Opioid Use during initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf

December 2019 119

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf

Part D Opioid - SE 18016• 2019 Medicare Part D opioid overutilization

initiative effective January 2019• CMS published roadmap with details & three-

pronged approach to epidemic:1. Prevention of new cases of OUD; 2. Treatment of patients who already became

dependent or addicted to opioids; and 3. Utilization of data from across the country to better

target prevention and treatment activities. • https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/ Downloads/SE18016.pdf

December 2019 120

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18016.pdf

Chronic Pain NCDs - SE 19008• Integrative & Non-Pharmacological Chronic

Pain Management effective August 2019– Summarizes other chronic pain treatment options

• National Coverage Determinations (NCDs): – Electrical Nerve Stimulation (NCD 160.7)– Induced Lesions of Nerve Tracts (NCD 160.1)– Outpatient hospital pain rehabilitation (NCD 10.4) – Supervised exercise therapy for symptomatic

peripheral artery disease (NCD 20.35)• https://www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/ MLNMattersArticles/ downloads/SE19008.pdf

121December 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19008.pdf

Reducing Opioid Misuse • CMS continues

promotion of safe pain management

• CMS roadmap updates• Video series• Learn more

– https://www.cms.gov/about-cms/story-page/reducing-opioid-misuse.html

December 2019 122

https://www.cms.gov/about-cms/story-page/reducing-opioid-misuse.html

Thank You for Attending!

Reminders

• Take short polling survey – Pops up after closing out of webinar

• PDF on website under Drugs, Biologicals and Injections-Opioid Use Disorder

• No CEUs offeredThank you everyone for assisting our

Medicare beneficiaries!

124December 2019

CMS feedback Dec. 11 Webinar• Circumstances When More Than One OTP Can Bill for the Same Beneficiary in the

Same Week• There are limited clinical scenarios when a beneficiary may appropriately receive OUD

treatment services at more than one OTP within a 7 contiguous day period, such as for guest dosing or when a beneficiary transfers care between OTPs. In these limited circumstances, each of the involved OTPs may bill the appropriate HCPCS codes that reflect the services furnished to the beneficiary. We expect that both OTPs involved would provide sufficient documentation in the patient’s medical record to reflect the clinical situation and services provided. We will monitor the claims data to ensure that this flexibility is not abused.

• Availability of Locality Rate Charts• Locality Rate charts and information for OTPs to identify their locality-adjusted payment

rates are posted on our Billing & Payment page.• Physician Fee Schedule Final Rule – A Valuable Resource• Review of the final rule may be extremely helpful in increasing comfort with the policies for

this new benefit.•• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-

Program/billing-payment

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program/billing-payment

https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program/billing-payment

Tribal Opioid Response (TOR) grants• OIG The Substance Abuse and Mental Health Services

Administration (SAMHSA) has awarded a series of grants to combat opioid use disorder. These grants include State Targeted Response to the Opioid Crisis grants (Opioid STR) with approximately half of $970 million awarded in fiscal year (FY) 2017 and the other half awarded in FY 2018. In FY 2018, SAMHSA also awarded more than $930 million in the State Opioid Response grants (SOR) and approximately $50 million in Tribal Opioid Response grants (TOR). The purpose of the Opioid STR, SOR, and TOR grants are to increase access to treatment, reduce unmet treatment need, and reduce opioid overdose related deaths. This post-award audit will determine how select States or Tribal agencies implemented programs under the Opioid STR, SOR, or TOR grants.

• https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000427.asp

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000427.asp

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