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Configure Add-on Codes - PM

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Intake Activities Add-On Code (New Patient Only)

Per CMS, ‘the add-on code describing intake activities (HCPCS code G2076) should only be billed for new patients (that is, patients starting treatment at the OTP).’  If your agency provides such intake activities, which are outlined in the official documentation from CMS (link to that literature can be found at the end of this document), then you can bill G2076 as an add-on code.

Like the drug and non-drug bundles, a new roll-up definition will need to be created for the add-on code. The component services will be comprised of various qualifying intake activities as outlined by CMS.

 

Weekly Take Home Add-Ons

Depending on the client’s MAT regimen, there might be a take home dose. According to CMS guidelines:

  • HCPCS Code G2078 – Take-Home Supplies of Methadone – Describes up to 7 additional days of medication and is billed along the respective weekly bundled payment in units of up to 3 (for a total of up to one-month supply). This add-on code is only used with the methadone weekly episode of care code (HCPCS code G2067).
  • HCPCS Code G2079 – Take-Home Supplies of Buprenorphine (Oral) – Describes up to 7 additional days of medication and is billed along the respective weekly bundled payments in units of up to 3 (for a total of up to one-month supply). This add-on code is only used with the buprenorphine (oral) weekly episode of care code (HCPCS code G2068).

According to SAMHSA, an agency can only bill three units of the take-home add-on per one unit of the in-clinic methadone or buprenorphine doses:

In order to bill the take-home dose in myAvatar, the take-home doses will need to be configured as a roll-up. If you have take-home doses for both methadone and buprenorphine (oral), they will need to be configured as separate roll-up definitions. The configuration of those roll-ups is as follows:

Component Services – Select the service code that can be a part of the weekly take-home bundle. The take-home drug code should be the only component service selected.

            Component Service Date Rule – Select ‘Same Week (7 Days)’

Start Date of the Week - Select the appropriate start day of the week for your organization. Some organizations will start their weekly bundles on Sundays while others start them on Monday. CMS states, “OTPs may choose to apply a standard billing cycle by setting a particular day of the week to begin all episodes of care”, so this gives organizations flexibility in determining when their week will start. Other payors might have different guidelines, so please consult with your payor(s) to confirm the requirements.

Date of Service for Roll-Up Service – Select ‘First Day of the Week’. CMS states, “OTPs may choose to apply a standard billing cycle by setting a particular day of the week to begin all episodes of care. 

Is the Presence of Specific Services Required for the Roll-Up to Occur – Select ‘Yes – Require only one other service code category’.

Service(s) with One of the Following Other Service Code Categories Required for the Roll-up to Occur – Select the category that corresponds to the primary G-code. In the example of methadone that we’ve been using throughout this guide, it would be G2067. This will make the weekly drug bundle a prerequisite for the roll-up. If you need to setup an add-on role up definition for buprenorphine, it would be G2068. We discussed ‘Other Service Code Category’ on page 2 of this guide.

Time Frame For the Required Service(s) For the Roll-Up To Occur – This should be set to 27D. The reason we have a 27 day time frame limit is because G2078 (or G2079) “can be billed along with the base bundle in units up to 3 (for a total of up to one-month supply)”.

For example, let’s say the start day of your OTP billing cycle is Monday, so your OTP billing cycle runs Monday to Sunday. A client comes in everyday from 8/4/2021 to 8/7/2021 for in-clinic dosing of methadone. On 8/7, the client decides they will take home 27 take-home dose of methadone that should last them until 9/3/2021. According to CMS, you would bill G-2067 on the first day of your OTP billing cycle which is 8/2/2021 (even though the client started mid-week) that would cover the in-clinic doses from 8/4/2021 to 8/7/2021 and the take-home dose for 8/8/2021. The take-home doses from 8/9/2021 to 8/15/2021 counts as 1 unit of G2078. The take-home doses form 8/16/2021 to 8/22/2021 counts as your 2nd unit of G2078. The take-home doses from 8/23/2021 to 8/29/2021 counts as your 3rd unit of G2078. Per CMS guidelines, you can bill at most 3 units of the take-home dose for a given base code (G2067 in this case). You cannot bill the additional take-home doses from 8/30/2021 to 9/3/2021 without another valid G2067 base code. The last take-home dose you can bill (8/29/2021) is 27 days from the in-clinic methadone weekly bundle code that was dropped on 8/2/2021. This is why we enter 27D for this field.

 

Date To Use To Verify Time Frame for Days/Months Selections – This should be set to ‘Look Backward from Service Date’

Is This Roll-Up Service Dependent on Units, Duration, or None – Set this to ‘None’

Calculate Fixed Fee Charge By – Set this to ‘None’