01-111 OIG Opioid Use Disorder Treatment Notification of Medical Review
Noridian Healthcare Solutions, LLC, (Noridian) as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B opioid use disorder (OUD) services billed with dates of service from January 1, 2022, through September 1, 2022. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
Background
The Office of Inspector General (OIG), published a report (A-09-22-03005) titled “Medicare Made $17.8 Million in Potentially Improper Payments for Opioid-Use-Disorder Treatment Services Furnished by Opioid Treatment Programs”. The OIG conducted an audit on 2.1 million Medicare Part B OUD claims and identified potentially up to $17.8 million improper payments to Opioid Treatment Programs (OTPs).
Reason for Review
In response to the OIG report, the SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with OUD Healthcare Common Procedure Coding System (HCPCS) codes G2067, G2068, G2069, G2074, G2078, and/or G2079 billed with date of service January 1, 2022, through September 1, 2022.
The SMRC will conduct medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, sub-regulatory and coding guidance.
Claim Sample Detail
| HCPCS | Description |
|---|---|
| G2067 | Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2068 | Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2069 | Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2074 | Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program) |
| G2078 | Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
| G2079 | Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program); list separately in addition to code for primary procedure |
Access related project details below.
Documentation Requirements
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- History and Physical reports (include medical history and current list of medications)
- Beneficiary’s medical records (which may include prescribing/ordering practitioner medical records, hospital records, nursing home records, counselor notes, therapy notes) sufficient to evidence that the service(s) provided is/are reasonable and necessary
- Medical record documentation to support the dates of service billed on the claim
- Medication Administrative Record (MAR) to include all records clarifying the periods of billing cycles prior to and after the dates of service requested. Including whether the billing date of service is the first day, last, or another day of the 7-day billing episode.
- Physician/Non-Physician (NPP) order or evidence of intent to order, if applicable
- Documentation to support the medical necessity of service billed
- Initial evaluation (Provider H&P) / Start of therapy (Biopsychosocial assessment)
- Signed and dated treatment plan, with any updates to include the current dates of service under review
- Documentation to support medication assisted treatment, including the specific drug (e.g., methadone or buprenorphine), dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed
- Documentation to support an Opioid Use Disorder diagnosis code(s) for the service(s) billed
- Any other supporting/pertinent documentation
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC), if applicable
- If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
- PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met
References
Social Security Act (SSA), Title XI
- § 1135 Authority to Waive Requirements During National Emergencies
Social Security Act (SSA), Title XVIII
- § 1812(f) Scope of Benefits
- § 1815(a) Payment to Providers of Services
- § 1833(a)(1)(CC) Payment of Benefits, Opioid Use Disorder Treatment Services
- § 1833(e) Payment of Benefits
- § 1834(w) Special Payment Rules for Particular Items and Services, Opioid Use Disorder Treatment Services
- § 1861(jjj) Opioid Use Disorder Treatment Services; Opioid Treatment Program
- § 1861(s)(2)(A) Medical And Other Health Services
- § 1861(s)(2)(HH) Opioid Use Disorder Treatment Services and Supplies
- § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
- § 1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
- § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
- § 1893(b) Medicare Integrity Program
42 Code of Federal Regulations (CFR)
- § 8 Medication Assisted Treatment for Opioid Use Disorders
- § 410.67 Medicare Coverage and Payment of Opioid use disorder treatment services furnished by Opioid treatment programs
- § 411.15(k)(1) Any services that are not reasonable and necessary
- §424.5(a)(6) Basic Conditions and Sufficient Information
National Coverage Determination (NCD)
- NCD 130.6 Treatment of Drug Abuse (Chemical Dependency)
Public Law
- Public Law 115-271, October 24, 2018. Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act). Retrieved from PUBL271.PS (congress.gov)
Federal Register
- Federal Register. Volume (Vol.) 84, Number (No.) 221. Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollments Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule. November 15, 2019. Retrieved from CMS–1715–F and IFC
Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02
- Chapter (Ch.) 16 General Exclusion from Coverage
- Ch. 17 Opioid Treatment Program
IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 1 General Billing Requirements
- Ch. 23 Fee Schedule Administration and Coding Requirements
- Ch. 30, § 50 Advanced Beneficiary Notice (ABN) of Noncoverage
- Ch. 39 Opioid Treatment Programs (OTPs)
IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3 Verifying Potential Errors and Taking Corrective Actions
Other
- CMS. 2021 Medicare Physician Fee Schedule (PFS) Final Rule Summary for ASAM Members. January 2021. Retrieved from 2021-medicare-pfs-final-rule-summary_updated.pdf (windows.net)
- CMS. 2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F. Retrieved from CY2020 Final Payment Rates for Opioid Treatment Program (OTP) CMS-1715F
- CMS Fact Sheet. Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. December 1, 2020. Retrieved from Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021 | CMS
- CMS. Opioid Treatment Program. Retrieved from Billing & Payment | CMS
- Medicare Learning Network (MLN) 8296732, May 2020. Opioid Treatment Programs (OTPs) Medicare Billing & Payment Fact Sheet. Retrieved from Opioid Treatment Programs (OTPs) Medicare Billing and Payment Fact Sheet (hhs.gov)
- Office of Inspector General (OIG). Medicare Made $17.8 Million in Potentially Improper Payments For Opioid-Use-Disorder Treatment Services Furnished by Opioid Treatment Programs. August 2023. Retrieved from (A-09-22-03005 )
- OIG. Opioid Overdoses and the Limited Treatment of Opioid Use Disorder Continue to Be Concerns for Medicare Beneficiaries. September 2022. Retrieved from (OEI-02-22-00390 )
- U.S. Food & Drug Administration. Information about Medication-Assisted Treatment (MAT). Retrieved form Information about Medication-Assisted Treatment (MAT) | FDA
Last Updated Feb 7, 2024