Addiction Treatment Billing: CPT Codes, Site of Service & ASAM

Whether behavioral health providers are operating an opioid treatment program (OTP), a medication-assisted treatment (MAT) or an office-based opioid treatment (OBOT) they need to closely monitor insurance enrollments and reimbursements from submitted claims..

For example, many behavioral health insurance providers follow a practice known as site of service differential which directly impacts a facility or clinic's reimbursement rate. The main purpose of this policy is to clarify the Current Procedural Terminology (CPT) and Healthcare Common Procedural Coding System (HCPCS) relationship to a treatment center's reimbursement methodology.

Site of Service Differential:

The site of service differential acknowledges and records the location where a medical service was administered. As a policy, the service differential understands that healthcare practitioners usually have lower expenses when their treatments are provided in a facility environment.

Due to the fact that when procedures and therapies are administered in a facility setting, the healthcare provider is using hospital resources instead of their own. This will reduce the healthcare provider's own personal expenses.

Naturally, if the reimbursement methodology is in conflict, the participating healthcare practitioner's insurance contract rates will apply. Healthcare providers who are in-network, and are performing an eligible procedure, are reimbursed at the site of service differential rate. Otherwise, procedures and treatments performed in non-facility medical settings are reimbursed at the non-facility rate.

For example, Oxford commercial plans (part of United Healthcare) require these standards be met in order to apply a site of service differential rate:

• The medical treatment was administered in a CMS classified facility setting.
• The healthcare practitioner providing the service is a licensed medical physician.
• The healthcare practitioner administering the treatments is in-network.
• The procedure's CPT and HCPCS code are listed as eligible for a Site of Service Differential.

ASAM Levels of Care:

There is a continuum of care that centers and facilities should follow as they deliver addiction recovery services. The American Society of Addiction Medicine (ASAM) has created what is known as the ASAM levels of care. They include an early intervention level as well as four broad levels of service. In order to list and explain the full scope of addiction treatment services, these levels are helpful.

These levels of treatment services are composed of five stages. The ASAM Continuum of Care Levels are:

• Level 0.5: Early Intervention.
• Level 1: Outpatient Services.
• Level 2: Intensive Outpatient (IOP)/Partial Hospitalization Services (PHP).
• Level 3: Residential/Inpatient Services.
• Level 4: Medically Managed Intensive Inpatient Services.

Incorporated between the above-mentioned levels of care are additional gradations of intensity of services.

For billing purposes, the ASAM care levels correlate to the use of the proper CPT codes. For example, a case manager, who is an unlicensed healthcare provider, who is delivering services at an ASAM level 1 (outpatient services) or 2 (IOP & PHP) will likely use the H0006 CPT code. However, as the ASAM level increases, different CPT codes are needed.

For example, if a program operates for a minimum of 3 hours a day and at least for 3 days a week, and includes an assessment, treatment plan and counseling; this is likely considered an ASAM level 2.1. In this instance, it is a SUD intensive outpatient program that requires a CPT code of H0015.

These details do matter if clinicians expect to receive their reimbursements in a timely manner from insurance providers. Rejected and denied claims can quickly create aged accounts and damage a practice's cash flow. This is where the services of an experienced medical billing company can add value to a facility or clinic. A good medical billing company will also have the ability to work with multiple EHRs and PM systems.

Who We Are:

RevUp Billing delivers a complete suite of revenue cycle management tools for behavioral health professionals. This includes insurance enrollment and credentialing monitoring services. Their billing and credentialing specialists offer revenue cycle management (RCM) solutions that streamline a medical practice’s billing, coding and claims processing tasks. They also offer reliable billing and software services for I-DD Ohio Waiver provider agencies.

If you have questions about medical billing requirements for addiction treatment centers - contact us.

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Updated from original article published on April 12, 2021