Opioid analgesics — a class of prescription drugs used to treat both acute and chronic pain — have increasingly been implicated in drug overdose deaths over the last decade. Common opioid analgesics include hydrocodone, oxycodone, codeine, morphine, and methadone.
In a proposed rule, the U.S. Department of Health and Human Services (HHS) announced, March 29, its plan to allow qualified physicians to prescribe the opioid use disorder treatment medication buprenorphine (Subtext® or Suboxone®) to an increased number of patients.
Under current regulations, physicians certified to prescribe buprenorphine for medication-assisted treatment (MAT) are allowed to prescribe up to 30 patients initially and then after one year can request authorization to prescribe up to a maximum of 100 patients. HHS is proposing to allow for a qualified and currently waived physician to prescribe buprenorphine for up to 200 patients.
This proposed rule is part of HHS’ evidence-based efforts on prescribing practices and treatment to reduce prescription opioid and heroin use disorders. HHS efforts focus on three priority areas:
- Providing training and educational resources, including updated prescriber guidelines.
- Increasing use of naloxone.
- Expanding the use of MAT.
Waging its own battle, on March 6, the Centers for Disease Control and Prevention (CDC) launched the Prescription Drug Overdose Prevention for States Program to provide state health departments with resources to advance innovative prevention efforts.
The Centers for Medicare & Medicaid Services offers the Drug Diversion Toolkit: Buprenorphine—A Primer for Prescribers and Pharmacists. This booklet provides guidance to physicians and pharmacists on buprenorphine regulatory requirements, prescribing, dispensing, and safety recommendations, and additional information to improve decision-making and promote beneficial outcomes.
HHS is accepting public comment on the proposed rule, Medication Assisted Treatment for Opioid Use Disorders, for 60 days after the March 30 publish date in the Federal Register.
The Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction Consensus Panel recommends that physicians periodically and regularly screen all patients for substance use and substance-related problems, not just those patients who fit the stereotypical picture of addiction.
Note that, according to Quest Diagnostics, “Beginning January 1, 2016, CMS deleted all 2015 drug testing G codes and will continue to not recognize the AMA CPT codes for drug testing. CMS created three G codes for presumptive testing [G0477-G0478] and four G codes fore definitive testing [G0480-G0483].”
If screening indicates the presence of an opioid use disorder, further assessment is indicated to identify comorbid or complicating medical or emotional conditions, and to determine the appropriate treatment setting and level of treatment intensity for the patient. Complete assessment may require several office visits.
According to buppractice.com, “Primary Care Physicians (PCPs) have been successfully using standard evaluation and management outpatient billing codes for both the induction and maintenance stages of treatment.” However, bupractice.com says, “Some private health insurers are developing standard billing codes for buprenorphine treatment services.” For instance, Cigna tells clinicians to use HCPCS Level II code H0033 Oral medication administration, direct observation. Your best best is to reference individual payers’ policies for their specific coding preferences.
After a thorough assessment of a patient has been conducted, a formal diagnosis can be made. As a general rule, to be considered for buprenorphine maintenance, patients should have a diagnosis of opioid dependence, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000).
Opioid dependence is reported with DSM-5 codes 305.50 Opioid abuse or 304.00 Opioid dependence; ICD-10-CM code F11.2x Opioid dependence; or ICD-9-CM code 304.0x Drug dependence, depending on on the health plan. A fifth digit added to the ICD-10-CM or ICD-9-CM code provides further specificity, such as “uncomplicated” (F11.20) or “in remission” (F11.21) in ICD-10-CM, or “unspecified” (304.00) or “continuous” (304.01) in ICD-9-CM.