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CMS Proposes Modifications to Coverage for Opioid Use Disorder Treatment

 

Since January 1, 2020, CMS has made separate payment for the treatment of opioid use disorder when furnished by qualified opioid treatment practitioners (OTP). This new Medicare benefit, established by the SUPPORT Act, allows CMS to make bundled payments for weekly episodes of care. Medicare will pay for episodes of care that include drugs, for non-drug episodes of care, for intake and periodic assessments, take-home dosages of methadone and buprenorphine, as well as for additional counseling.




Pricing

The episodic payment rate includes reimbursement for the drug- and non-drug-components of the encounter. Pricing for the drug component of the bundle is set using the most appropriate pricing mechanism currently in place and varies depending on the drug. Annual updates to the drug component of the bundle are made using the most recently available data from the applicable pricing mechanism. The non-drug portion of the bundle is updated based on the Medicare Economic Index. To reflect variances in labor costs across the country, the non-drug portion is also updated using the geographic adjustment factor. In the proposed CY 2022 Medicare Physician Fee Schedule, CMS proposes to also update payment for take-home supplies using the geographic adjustment factor in addition to the MEI.

Duplicate Payments

In the CY 2021 final MPFS rule, CMS stated that payment to an OTP for naloxone would be considered duplicative if a claim for the same drug, for the same beneficiary, on the same date of service was paid by Medicare. Medicare would seek to recoup these duplicative payments. In the CY 2022 proposed rule CMS proposes to expand this policy such that payment for any medication, including but not limited to take-home supplies of naloxone, provided as part of an adjustment to the weekly bundle would be duplicative if a claim for the same drug, for the same beneficiary, on the same date of service was paid by Medicare.

Take-home Supplies

In CY 2021, CMS finalized HCPCS code G2215 to describe the take-home supply of naloxone. The code was priced on the assumption that a beneficiary would be prescribed a box of two 4 mg nasal spray products. Since then, an additional dosing size has become available. CMS is proposing to create a new HCPCS code to describe the higher, 8mg, dose. CMS would use the current ASP or WAC pricing methodology, without the additional add-on percentage, to price the new HCPCS code. Pricing would be based on the assumption that a typical dosage would be one box of two 8mg nasal spray bottles. The non-drug component of the new code would be determined based on the payment rate for CPT code 96161, and payment would be limited to once every 30 days.

Audio-Only Visits
Since 2020, CMS as allowed the use to audio/video two-way communication to provide OUD counseling and therapy to beneficiaries. During the COVID-19 public health emergency, CMS expanded this policy to allow audio-only two-way communications to provide counseling and therapy when audio/video technology is not available. This policy expansion is effective until the end of the PHE. CMS is proposing to extend this policy and allow the use of audio-only two-way communications beyond the end of the PHE, as long as the OTP can document that audio/video communication was not available to the beneficiary. OTPs would be required to document in the beneficiary’s medical record that audio/video communication was not available and would be required to append modifier -95 to the claim line for the therapy and counseling services.

Comments on these proposals are due to CMS by September 13, 2022.

For more information about this Medicare benefit, contact me at john@policypros.net.

The final rule is available online at: https://public-inspection.federalregister.gov/2021-14973.pdf




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