COVID-19 is not the only pandemic our nation is facing. Just last fall, the Centers for Disease Control and Prevention (CDC) announced that annual drug overdoses exceeded 100,000 for the first time in the U.S. for a 12-month period that ended in April 2021. Those deaths represent a 28.5 percent increase from just one year earlier.
Overdoses from opioids alone account for 75,673 of those deaths, up from 56,064 the year before. And those numbers represent just a small portion of people who misuse opioids. According to a 2019 National Survey on Drug Use and Health, 10.1 million people misused prescription opioids in the past year, 2 million people used methamphetamine in the past year, and 745,000 people used heroin in the past year. As well, more than 1.6 million Americans experience opioid use disorder (OUD) as a chronic condition.
Emergency Departments on the Frontline
Emergency departments (ED) serve on the frontline of the fight against drug overdoses and opioid use disorder. According to the latest available federal numbers, opioid-related ED visits increased by 110% between 2011 and 2018. Even more troubling, a study conducted by Dr. Scott G. Weiner and his colleagues from Brigham and Women’s Hospital in Boston along with the Massachusetts Department of Health, found that about 1 in 20 patients treated for a nonfatal opioid overdose in an emergency department died within one year of their visit, many within two days.
For many, medication assisted treatment (MAT) administered in the emergency department can be the first step toward recovery. A recent study supported by the National Institutes of Health’s National Institute on Drug Abuse (NIDA) found that high-dose buprenorphine therapy is safe and well tolerated in people with opioid use disorder experiencing opioid withdrawal symptoms when provided under emergency department care. While lower doses of buprenorphine are the current standard of care, the study’s authors found that “elevated doses of the medication may provide a critical extended period of withdrawal relief to people after being discharged from the emergency department that may help them navigate barriers to obtaining medications as well as accessing care for the treatment of opioid use disorder.”
“For many patients, quickly achieving a high dose of buprenorphine reduces opioid withdrawal, craving and overdose risk, and improves antidepressant effects,” said lead author Andrew Herring, MD, an emergency physician and the associate director of research at Highland Hospital-AHS, in Oakland, Calif. “These benefits should not be restricted to outpatient treatment.”
Unfortunately, a Michigan Medicine study published in the Annals of Emergency Medicine last November found that out of 149,000 emergency department visits for opioid overdose before and during the pandemic just 8.5 percent were prescribed buprenorphine and only 7.4 percent of patients received a prescription for naloxone within 30 days to help in future overdose scenarios.
“In light of the record levels of opioid overdose deaths, the low levels of naloxone and buprenorphine prescribing are simply unacceptable,” says Kao-Ping Chua, M.D., Ph.D., lead author of the study and assistant professor of pediatrics at Michigan Medicine. “Clinicians are missing critical opportunities to save lives both in the emergency department and during follow-up after overdose visits.”
Barriers to Care
In the past, several barriers prevented emergency physicians from offering MAT for opioid use disorder, including the X-waiver and its onerous training requirements, along with the Three-Day Rule. We’ve written at length about both of those policies, along with recent changes that makes administering and prescribing MAT much easier for emergency department physicians.
For instance, a 2021 exemption now means providers can simply submit a Notice of Intent to the Substance Abuse and Mental Health Services Administration (SAMHSA) to receive an X-waiver for treating up to 30 opioid use disorder patients with buprenorphine without the typical training, counseling, and other ancillary services requirements.
Also, amendments 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.”
The law required the DEA to make changes to the regulations within six months from the date the bill was enacted, or by June 9, 2021, though nothing has happened to date. Until changes are made, the current Three-Day Rule remains in place, though ACEP expects to see revised regulations early this year.
Finally, through 2020, there was no specific code to use for MAT in the ED, nor did Medicare reimburse for MAT in the ED. In the 2021 Medicare Physician Fee Schedule, both of those things changed.
Documenting and Coding for MAT
Whether with an X-waiver or under the Three-Day Rule, when emergency physicians do administer and/or prescribe MAT, what should they document and how should they code for their services?
According to Jenn Sheese, COC, CPC, CPMA, CEDC, CIPROMS Auditor and Medical Coder, documentation should include following:
- Medical Necessity
- Reason why MAT is being considered – presenting with OD or withdrawal, presenting with complication related to opioid use, patient request
- Determination if the patient has an opioid use disorder
- Readiness to start MAT
- Suitability for initiation – COWS (clinical opiate withdrawal scale)
- Follow-up plan
Sheese suggested the following documentation template to help providers ensure they have included all the necessary information:
Patient presented with [***] and was assessed for OUD using DSM-V criteria. Pt has demonstrated readiness to start MAT, and plan to initiate buprenorphine (16mg qdx 7d) therapy today. Pt has been seen by SBIRT/peer rec overy coach and follow up has been arranged [***timeline, facility]. Pt was given an rx for naloxone. Dx: Opioid overdose, OUD
Finally, providers should use add-on G-code G2213 for medication assisted treatment of opioid use disorder in the ED setting. Because it’s an add-on code, it must be billed with an ED E/M visit code. The G2213, which was assigned a work RVU of 1.30, covers the resource costs involved with initiation of medication for the treatment of opioid use disorder and referral for follow-up care. It also includes payment for assessment, referral to ongoing care, follow-up after treatment begins, and arranging access to supportive services. The drug itself is paid separately.
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