Providing and Billing for Medication Assisted Treatment for Opioid Use Disorder in the ED

In the 2021 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) finalized the creation of add-on G-code, G2213, to be billed with E/M visit codes used in the ED setting for medication assisted treatment (MAT) of opioid use disorder.

The new code will cover the resource costs involved with initiation of medication for the treatment of opioid use disorder and referral for follow-up care. G2213 also includes payment for assessment, referral to ongoing care, follow-up after treatment begins, and arranging access to supportive services. The drug itself will be paid separately.

CMS used a direct crosswalk to the work and direct PE inputs for HCPCS code G0397 (Alcohol/subs interval >30 min), because of the “similar nature and magnitude” of the two services. Which means that G2213 will be assigned a work RVU of 1.30.

Having a code to use, however, is not the only hurdle for emergency physicians to cross in providing and billing of MAT for the treatment of opioid use disorder.

X-Waiver

The X-waiver requirement was part of the Drug Addiction Treatment Act (DATA) of 2000, passed by Congress to address the growing opioid crisis. DATA allows physicians with an X-waiver to treat opioid use disorder with buprenorphine, an alternative to the heavily regulated methadone. However, the X-waiver requires eight hours of training for physicians (24 hours for advanced practice providers), an application to the federal Substance Abuse and Mental Health Administration, and an often lengthy waiting period of up to 90 days before the waiver is granted.

According to American College of Emergency Physicians (ACEP), “the X-waiver presents a major obstacle to ‘legitimate’ patient access to buprenorphine and other MAT,” particularly for emergency physicians. It also “has led to misperception about MAT and has increased negative pre-conceived notions about OUD and the treatment of this disease. As a result, some clinicians are hesitant to pursue this DEA license or even engage in treatment of patients with OUD.”

On January 14, 2021, the Department of Health and Human Services (HHS) issued an exemption to the X-waiver for physicians who are already registered with the Drug Enforcement Administration (DEA) and treat no more than 30 patients with buprenorphine for opioid use disorder at any one time. According to ACEP, HHS also included emergency physicians in the waiver, recognizing “the unique nature of emergency medicine.”

However, on January 27, 2021, days after the Biden administration took the helm, HHS and the Office of National Drug Control Policy (ONDCP) announced that the guidelines had been released prematurely and “cannot be issued at this time.” HHS and ONDCP also acknowledged, however, that they are “committed to working with interagency partners to examine ways to increase access to buprenorphine, reduce overdose rates and save lives.”

Legislation also has been introduced by Sens. Maggie Hassan (D-N.H.) and Lisa Murkowski (R-Alaska), along with four members of the House of Representaives, to eliminate the X-waiver requirement and change the prescribing rules to allow more physicians to use MAT to treat opioid use disorder. According to The Washington Post, the legislators sent a letter to President Biden, calling on him to “deliver on your promise to expand access to medication-assisted treatment.”

In the meantime, emergency physicians who want to use MAT for patients with opioid use disorder can take the required training and apply for the X-waiver—ACEP provides an emergency department (ED)-specific waiver training course—as well as take advantage of another X-waiver exception that will be expanded later this year.

Three-Day Rule

The Three-Day Rule currently allows non-waivered physicians to administer, but not prescribe, buprenorphine or other “narcotic drugs” to a person “for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral for treatment. Not more than one day’s medication may be administered to the person or for the person’s use at one time. Such emergency treatment may be carried out for not more than three days and may not be renewed or extended.”

Changes to the Three-Day Rule were included in a short-term funding bill signed into law on December 11, 2020. The Easy MAT Act, sponsored by emergency physician and U.S Representative Raul Ruiz (D-CA), requires the Attorney General (acting on behalf of the DEA) to revise the Three-Day Rule to allow “practitioners, in accordance with applicable State, Federal, or local laws relating to controlled substances, to dispense not more than a three-day supply of narcotic drugs to one person or for one person’s use at one time for the purpose of initiating maintenance treatment or detoxification treatment (or both).”

According to Jeffrey Davis, Director of Regulatory Affairs at ACEP, the key is that “under this new law, practitioners (not just physicians) will be allowed to dispense three-days’ worth of medication at one time. Therefore, patients can presumably receive one day’s-worth of medication while at the ED and then take the two remaining days-worth home, saving them from having to make subsequent trips to the ED.”

While the changes to the Three-Day Rule have not yet been enacted, the law requires the DEA to make them within six months from the date the bill was enacted, or by June 9, 2021. Until that time, the current Three-Day Rule is still in place, which allows emergency physicians to provide MAT one day at a time for up to three days, with the patient presenting to the ED in person each of the three days.

Learn More

For more information about the fight against opioid use disorder, and more specifically MAT, the X-waiver, and the Three-Day Rule, check out the following resources: