Understanding the Latest CMS Guidelines for Substance Use Disorder Billing

On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) released its final rules for the Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for Calendar Year 2024. The new guidelines bring significant updates to substance use disorder (SUD) treatment, focusing on expanding access to services, addressing reimbursement rates, and incorporating new billing codes. These changes aim to improve the quality of care for Medicare beneficiaries with substance use disorders and address the ongoing opioid and mental health crises in the U.S. Let’s have a look at the latest CMS guidelines for SUD billing:

CMS Guidelines for Substance Use Disorder Billing

1. Expanded Coverage for Mental Health Counselors and Marriage and Family Therapists:

Starting January 1, 2024, mental health counselors (including addiction counselors) and marriage and family therapists can enroll in Medicare to treat beneficiaries with mental health conditions and substance use disorders. These practitioners must have a master's or doctorate in counseling, state certification, and at least two years or 3000 hours of supervised clinical experience. They will be reimbursed at 80% of the lesser of the actual charge or 75% of the PFS rate for psychologists. This new rule is expected to allow approximately 200,000 new counselors to participate in Medicare, but the reimbursement rate remains an issue compared to the higher 85% for non-physician medical practitioners.

2. Limitations on Reimbursement for Certain Practitioners:

Though the inclusion of new practitioners is a positive step, the lower reimbursement rates for mental health counselors and marriage and family therapists may hinder their ability to provide services at a sustainable level. Additionally, not all states have licensed addiction counselors, resulting in uneven access to substance use disorder care across the country.

3. Introduction of New Billing Codes for Social Determinants of Health (SDOH):

CMS introduced new service codes—Community Health Integration (CHI) and Principal Illness Navigation (PIN)—to allow peer support specialists and community health workers to address SDOH needs under the supervision of Medicare providers. These codes facilitate SDOH-related services in collaboration with community-based organizations. However, only providers who can bill Evaluation and Management (E/M) codes or psychologists can initiate these services, excluding clinical social workers, mental health counselors, and marriage and family therapists.

4. Coverage for Intensive Outpatient Programs (IOP):

A significant change is the new coverage for Intensive Outpatient Programs (IOP), structured outpatient services requiring a minimum of 9 hours but less than 20 hours of therapy per week. This new benefit is reimbursable in hospital outpatient departments, community mental health centers, federally qualified health centers, rural health clinics, and opioid treatment programs (OTPs). The IOP coverage extends to beneficiaries with mental health and substance use disorder diagnoses. However, coverage is limited in freestanding substance use disorder treatment facilities, where many individuals with SUDs receive IOP services, particularly those with alcohol use disorder.

5. Reimbursement Rate Increases for Substance Use Disorder Services:

To address the workforce shortage and the increased need for mental health and substance use disorder services, CMS has raised reimbursement rates for psychotherapy codes, behavioral health integration codes, and bundled substance use disorder codes (G2086-G2088). Though the rate increases are a step in the right direction, experts argue that more structural reforms are necessary to fully meet the growing demand for these services and reduce the disparity between mental health services and traditional medical services.

6. CPT Codes for Substance Use Disorder Billing:

Accurate coding is critical for substance use disorder billing, and CMS utilizes Current Procedural Terminology (CPT) codes to standardize the billing process. Some of the most commonly used CPT codes for SUD billing include:

• Evaluation and Management (E/M) Codes: Capture the complexity of services provided during patient evaluations. (E.g., 99201-99205 for new patients, 99211-99215 for established patients)
• Behavioral Health Assessment Codes: Document comprehensive assessments of patients’ mental health and substance use. (E.g., 90791, 90792)
• Psychotherapy Codes: Capture various types of therapy, including individual, group, and family therapy. (E.g., 90832, 90834, 90837, 90853)
• Medication Management Codes: Reflect evaluating and managing medications for substance use disorders. (E.g., 90863, 96116)
• Detoxification and Withdrawal Management Codes: Document services for managing withdrawal symptoms. (E.g., 99408, 99409)

Outsourcing to 24/7 Medical Billing Services

As the new CMS guidelines introduce more complex billing codes and regulations, healthcare providers may find it increasingly challenging to manage billing in-house. This is where outsourcing medical billing to specialized companies becomes a valuable solution. Billing companies, such as 24/7 Medical Billing Services, are equipped with the expertise to deal with the latest CMS updates and ensure compliance with billing requirements.

The company also provides the presence of experienced billers who are adept at using accurate codes and avoiding denials, leading to faster payments and optimized reimbursements. Therefore, there is a need to adjust to these new rules and deal with the complexities of billing as providers, whereby outsourcing billing to specialized companies can further streamline your operations.