Understanding the New SUD Facility Billing Guidelines Coming May 2024

The Centers for Medicare & Medicaid Services (CMS) announced significant updates to the Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for Calendar Year (CY) 2024, introducing new coverage options for substance use disorder (SUD) treatment for Medicare beneficiaries. These changes aim to close longstanding gaps in Medicare coverage, enhance access to care, and address the ever-changing needs of individuals grappling with substance use disorders and mental health conditions.

New SUD Facility Billing Guidelines

  1. Inclusion of Mental Health Counselors & Marriage and Family Therapists:

With the release of the new rules, mental health counselors and marriage and family therapists have gained official enrollment eligibility in Medicare, effective January 1, 2024. This inclusion marks a significant step forward in expanding beneficiary access to substance use disorder counseling.

  1. Coverage of Peers & Community Health Workers:

While not directly billable under Medicare, peer support specialists and community health workers now have the opportunity to address the social determinants of health (SDOH) needs of Medicare beneficiaries through new service codes. This initiative enhances the support network available to individuals with mental health conditions and substance use disorders.

  1. Expansion of Intensive Outpatient Treatment (IOP) Coverage:

The coverage scope for intensive outpatient treatment (IOP) has been widened, encompassing various settings such as hospital outpatient departments, community mental health centers, and opioid treatment programs (OTPs). This expansion ensures that beneficiaries with mental health or substance use disorder diagnoses can access vital treatment services.

  1. Reimbursement Rate Increases:

CMS has responded to concerns regarding low reimbursement rates for mental health and substance use disorder services by implementing rate increases for relevant services. However, further reforms are necessary to bridge the reimbursement gap between these services and medical care.

Now What Next?

The updates to Medicare’s coverage for substance use disorder treatment signify a crucial step in addressing the complex needs of Medicare beneficiaries struggling with mental health and substance use disorders. While these changes mark significant progress, further new billing guidelines are introduced for Substance Use Disorder (SUD) treatment facility, effective May 1, 2024. These guidelines aim to ensure proper billing practices are followed to avoid claim denials. These are as follows:

Requirements for Billing:

In order for claims to be eligible for reimbursement, the following criteria must be met:

  • Facility Bed Capacity: The SUD treatment facility must have more than 16 beds.
  • Member Criteria: The member receiving treatment must be under the age of 65 and have a primary diagnosis of Substance Use Disorder (SUD).

Provider Type Specific Billing Instructions:

  1. Physician Group:
    • Claim Form: Billing must be done using the 1500 claim form.
    • Required Modifier: Include the V1 modifier on all claims.
    • CPT or Revenue Codes:
      • H2034: Low-Intensity Adult (ASAM Level 3.1)
      • H2034-U4: Low-Intensity Adolescent (ASAM Level 3.1)
      • H0018: High-Intensity Adult (ASAM Level 3.5)
      • H0018-U4: Medium-Intensity Adolescent (ASAM Level 3.5)
      • H0010: Medically Monitored Residential Withdrawal Management (ASAM Level 3.7-WM)
      • T1006: Specialty Residential Services for Pregnant & Parenting Women
  1. SUD Residential Facilities:
  • Claim Form: Use the UB04 claim form.
  • Required Condition Code: A3 Condition Code must be included on all claims.
  • CPT or Revenue Codes:
    • 1002: Behavioral Health Accommodations – Residential Treatment – Chemical Dependency
  1. Inpatient Hospitals:
  • Claim Form: UB04 claim form should be used.
  • Required Condition Code: A3 Condition Code must be included on all claims.
  • CPT or Revenue Codes:
    • 0116: Room & Board – Private (One Bed) – Detoxification
    • 0126: Room & Board – Semi-private (Two Beds) – Detoxification
    • 0136: Room & Board – Three and Four Beds – Detoxification
    • 0146: Room & Board – Deluxe Private – Detoxification
    • 0156: Room & Board – Ward – Detoxification

Outsourcing SUD Facility Billing

Providers and facilities must adhere to these billing guidelines when submitting claims for SUD facility. In fact, the failure to comply with these guidelines may result in claim denials. It is essential to carefully review and implement these guidelines to ensure seamless reimbursement for provided services. In fact, these new guidelines aim to improve access to substance use disorder treatment for Medicare beneficiaries. However, challenges such as reimbursement rates and coverage limitations for certain settings and conditions still exist.

Thereby, you can also opt for outsourcing your SUD billing and coding to mitigate challenges posed by reimbursement rate disparities and coverage limitations for specific settings and conditions in substance use disorder treatment. Not only this but outsourcing your specialized services to 24/7 Medical Billing Services can help you to understand the gaps in coverage better to enhance your access to comprehensive care for individuals with substance use disorders.

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