ED Coding and Reimbursement Alert

EDs can now bring in reimbursement for medication-assisted treatment.

When patients with opioid use disorder (OUD) present to the ED, clinicians may choose to treat them with medications like suboxone or buprenorphine. Although it was challenging to get paid for these medication assisted treatment (MAT) visits in the past, that all changed when the 2021 Medicare Physician Fee Schedule (MPFS) final rule announced that Medicare would finally pay for MAT delivered in the ED.

If you’ve got questions about how to document and bill for these services, we’ve got answers. Find out how you can bring in reimbursement for your ED’s MAT claims.

Know the Codes

To report MAT, you’ll use the newly debuted add-on code G2213 (Initiation of medication for the treatment of opioid use disorder in the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services (List separately in addition to code for primary procedure)).

Because G2213 is an add-on code, you’ll report it along with the appropriate E/M code (99281-99285, Emergency department visit for the evaluation and management of a patient …) with no modifiers appended. CMS values G2213 at 1.89 Total RVUs, which translates to about $66 this year.

When it comes to your diagnosis coding, you should typically report a diagnosis of OUD with an ICD-10 code from the F11 (Opioid related disorders) family of codes, said Jeffrey Davis, director of regulatory affairs with the American College of Emergency Physicians.

Understand the Documentation Rules

In the MPFS final rule, CMS says you “should furnish only those activities that are clinically appropriate for the beneficiary that is being treated.” However, many ED providers believe this guidance is somewhat vague.

Therefore, you should try to be as thorough as possible in your documentation to support these services, Davis noted.

“What we are suggesting is to document exactly what

you did,” he said. “Write a note describing the indications for MAT, the specific medications employed, and the follow-up process,” he said. “We have not gotten an official word from CMS. But the agency definitely says in the rule that you don’t need to furnish every single part of the service, only those that are clinically appropriate.”

You Need an X-waiver to Prescribe Buprenorphine, but the ED is Unique

Currently, office-based physicians must have an X-waiver before being able to prescribe medications like buprenorphine.

If you don’t have an X-waiver, you’ll have to apply for the program and take an eight-hour training course before receiving a waiver from the DEA.

ED Caveat: Physicians who don’t have an X-waiver may still be able to report G2213. Non-waivered physicians can initiate MAT in the ED by providing one day’s worth of medication to a patient each day over a three-day period. However, this “Three-day Rule” will be adjusted favorably at some point in the next few months.

“While well intended, the Three-day Rule is a barrier, because it forces the patient to come back to the ED three days in a row,” Davis said. The Easy MAT Act, which was signed into law on December 11, 2020, will allow providers (not just physicians) to dispense three days’ worth of medication at a time rather than making the patient come back multiple times over the three-day period. The Act requires the DEA to make this important change to the Three-day Rule by June 2021, Davis said.

Bottom line: Code and document your MAT services thoroughly and appropriately and continue to follow the Three-day Rule if you don’t have an X-waiver on file, keeping in mind that the Three-day Rule will potentially be modified later this year.