To ensure proper payment, hospitals must follow these special billing instructions. Failure to follow these special billing instructions could result in an overpayment that will be subject to recoupment and could subject the provider to sanctions for improper billing.
Overview
Under Appendix M and N of the current MassHealth Acute Hospital Request for Applications (as amended from time to time, the “Acute Hospital RFA” or “RFA”) applicable to in-state providers, and as applicable to out-of-state acute hospital providers under regulations at 130 CMR 450.233(D), participating in-state and out-of-state MassHealth acute hospital providers will be paid for Evaluation and Initiation of Medication for Opioid Use Disorder, and for Recovery Support Navigator Services, which are set forth in the Acute Hospital RFA.
Evaluation and Initiation of Medication for Opioid Use Disorder (MOUD) Services
The following billing instructions apply to outpatient claims where the evaluation and initiation of MOUD is carved out of the APAD submitted by Acute Outpatient Hospitals (Provider Type 80), referred to as “Hospitals” in this Part V:
Along with the member’s name, date(s) of service, and other usual information, the DDE claim for the BH crisis management Service must also include:
- The add-on code G2213. This option should be used for the provision of Evaluation and Initiation of MOUD Services, in accordance with Appendix M. This service is designed for individuals presenting to the emergency department for any medical or behavioral health condition, who are then identified as having signs or symptoms of an untreated opioid use disorder. When such a patient is identified, their presenting problem must be treated as standard of care requires. A qualified prescriber may offer the patient medication to treat opioid use disorder, and if they consent, the prescriber should initiate medication for the treatment of opioid use disorder.
- As described in Appendix M, the Hospital may bill for no more than one unit of G2213 per day.
Recovery Support Navigator (RSN) Services
The following billing instructions apply to outpatient claims where RSN services are carved out of the APAD in the ED submitted by Acute Outpatient Hospitals (Provider Type 80) or out of the APEC in Acute Inpatient Hospital units (Provider Type 70), referred to as “Hospitals”:
Along with the member’s name, date(s) of service, and other usual information, the DDE claim for the BH crisis management service must also include:
- The procedure code and modifier for RSN services as set forth in 101 CMR 444, with each unit billed representing 15 minutes of service. RSN services are designed for individuals presenting to the emergency department or who are admitted to a medical/surgical floor, who are identified as having signs or symptoms of an untreated opioid use disorder.
- If the patient presents to the ED and their presenting condition has stabilized so that they may be safely discharged from the ED to the community, members should be offered RSN services, so that the patient may be connected to an outpatient level of care that can maintain them in long-term SUD recovery.
- If the patient’s presenting condition requires that they be admitted to the medical/surgery floor or other acute care setting within the hospital, the patient should also be offered RSN services as part of their discharge plan from the acute care setting so that the patient may be connected to an outpatient level of SUD care that can support them in long-term SUD recovery.
- As described in Appendix N, there are no limits on how many units of RSN services may be billed in one day.
| Date published: | April 30, 2024 |
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