G0535, Patient navigational services, provided directly or by referral; including
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.
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.
3 Active Policies
PALMETTO-JJ-L39849, Opioid Treatment Programs
JJ
PALMETTO-JM-L39849, Opioid Treatment Programs
JM
A59718, Billing and Coding: Opioid Treatment Programs
Related Codes
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