This policy applies to MOUD providers.
Description
Medication for Opioid Use Disorder (MOUD) is the use of medications approved by the US Food and Drug Administration (FDA), in combination with behavioral therapies and support services, to provide a whole‐patient approach to the treatment of alcohol and opioid use disorders.
This policy pertains to the following MOUD providers:
Opioid Treatment Program (OTP)
Must meet the following criteria:
- OTP services must be provided by a practitioner affiliated with a MOUD program accredited by a SAMHSA Approved Opioid Treatment Program Accrediting Body.
- OTPs must provide medical, counseling, vocational, educational and other assessment, and treatment services either onsite or by referral to an outside agency.
Office-based Opioid Treatment (OBOT)
- Must provide medical, counseling, vocational, educational and other assessment, and treatment services, either onsite or by referral to an outside agency.
Policy Statement
The following criteria must be met for the member:
- Diagnosed with moderate or severe opioid use disorder.
- Agree to initiate MOUD and receive other services identified in the member’s behavioral health treatment plan.
MOUD INTAKE
MOUD Intake may be reimbursed for the first week of the members enrollment into the MOUD program by billing an appropriate Psychiatric diagnostic evaluation or Evaluation & Management code.
MOUD ESTABLISHED
MOUD Established can be billed weekly after the MOUD Intake has been completed.
MOUD Established visits must include the following criteria:
- The member receives their weekly medication for the week being billed.
- For OTPs, a clinical assessment must be conducted either face to face or via telehealth at least once every 3 months for the first year of treatment and at least once every 6 months for each subsequent year.
- Pregnancy tests for HCG (if clinically appropriate).
- Drug testing when clinically appropriate.
- Any labs or tests performed as part of clinical protocols for their substance use treatment.
- Must update members behavioral health individual treatment plan at least every two months.
Medication can be billed in conjunction with receiving MOUD established weekly bundled services.
Coding and Billing Guidelines
Services must be billed on the CMS-1500 claim form.
