Does G0534 require prior authorization?

No, G0534 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0534?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`G0534` — Coordinated care and/or referral services, such as to adequate and accessible community resources to address unmet health-related social needs, including harm reduction interventions and recovery support services a patient needs and wishes to pursue, which significantly limit the ability to diagnose or treat an opioid use disorder; each additional 30 minutes of services (provision of the services by a medicare-enrolled opioid treatment program); (list separately in addition to each primary code)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Claims for ambulatory non-residential OTP services should identify the place of service as code 58 (non-residential opioid treatment facility).
Billing and coding must follow the complementary Local Coverage Determination L39849 requirements and any documentation/medical record requirements specified therein.

Confirmation of OUD diagnosis documented in the medical record.

Complete medical history inclusive of concomitant medical conditions, psychiatric disorders, trauma, infectious disease, and pregnancy status must be documented.

Physical examination documented unless assessment is performed via telehealth.

Mental health screening for psychiatric disorders must be documented.

Key Coverage Criteria

Opioid treatment programs (OTPs) providing treatment for opiate use disorder (OUD) in non-residential opioid treatment facilities on an ambulatory basis are addressed by this billing and coding article.
Beneficiary has a diagnosis of opioid use disorder (OUD) established using the Diagnostic and Statistical Manual for Mental Disorders.
Beneficiary voluntarily chooses maintenance treatment for OUD.
Beneficiary is currently addicted to an opioid drug at time of admission.
Initial assessment must be completed upon admission and before initiating pharmacotherapy in compliance with 42 CFR 8.12(f)(2) and (4).
Treatment must be provided as part of a certified opioid treatment program (OTP) in accordance with 42 CFR 8.11 for coverage.

2 Active Policies

A59718 — Billing and Coding: Opioid Treatment Programs

L39849 — Opioid Treatment Programs

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