1. What is Medication Assisted Treatment (MAT)?
Medication Assisted Treatment (MAT) is the use of medications, such as Buprenorphine or Suboxone, to treat Opioid Use Disorders (OUDs). There was previously not a reimbursement paradigm for MAT in the emergency department (ED), but based on ACEP advocacy, CMS finalized its proposal to pay for MAT delivered in the ED starting in 2021.
2. What documentation is required to report MAT?
CMS states that one should “should furnish only those activities that are clinically appropriate for the beneficiary that is being treated.” While not specifically noted to be required, a good practice would be to write a note describing the indications for MAT, the specific medications employed, and the followup process as well as including a diagnosis of OUD with an ICD-10 from the F11 family of codes.
3. How should I report MAT on my ED claims?
Starting in 2021, add on code G2213 (Initiation of medication for the treatment of opioid use disorder in the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services) is available to report MAT.
For 2023, when provided in a facility setting, CMS values G2213 at 1.86 Total RVUs and 1.30 Work RVUs.
For 2023, Medicare will pay about $61.50, which is between a 99282 and 99283 (ED E/M code levels 2 and 3).
G2213 is an add-on code, and is reported in addition to a regular ED visit (evaluation and management) service.
4. What is an X-waiver and how does that apply to MAT?
Currently, physicians need to receive an “X-waiver,” as required by the Drug Addiction Treatment Act of 2000 (DATA 2000), in order to prescribe buprenorphine, methadone, or naloxone to patients with OUD in settings other than opioid treatment programs (such as the ED). To complete this mandated process, physicians must take an eight-hour training course, apply for the waiver from the federal Substance Abuse and Mental Health Administration, and eventually receive the waiver from the U.S. Drug Enforcement Administration (DEA). Although ACEP has provided an ED-specific waiver training course, we have long argued that this requirement creates a significant barrier to treatment and have advocated for its removal.
At the end of 2022 Congress passed the “Mainstreaming Addiction Treatment (MAT) Act” (H.R. 1384/S. 445), finally repealing, and thus eliminating the X-waiver. However, as of January 2023, guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA) about the removal of the X-waiver requirement. In the meantime, the existing X-waiver requirements are still in effect.
5. Is the x-waiver still required for emergency physicians to prescribe buprenorphine?
Yes, as of January 2023 the X-waiver is still required.
6. If emergency physicians do not have an X-waiver, can they still bill the add on code G2213?
To bill for the add-on code G2213, emergency physicians must furnish services that are clinically appropriate for the patient related to the initiation of MAT in the ED. This includes assessment, referral to ongoing care, and arranging access to supportive services.
When initiating MAT in the ED, emergency physicians must abide by existing laws and regulations. On the federal level, this includes the X-waiver requirement for prescribing buprenorphine, and the current Three-Day Rule, which allows non-waivered physicians to administer one day’s worth of medication to a patient at one time—over a three-day period.
7. Can a resident prescribe buprenorphine?
Healthcare practitioners, including physicians, must have a X-waiver from the Drug Enforcement Administration (DEA) to prescribe buprenorphine. Currently, residents are not able to get a DEA X-waiver until they have a personal DEA number— as opposed to the "educational limited" DEA license which is tied to the academic center. Some residents train and practice under their institution or hospital’s DEA number, so they do not obtain their own personal DEA numbers. If a resident physician obtains their own personal DEA license, they may complete the required training and apply for an X-waiver.
In order to receive a personal DEA number, residents must hold an active license in the state where they are going to practice. If the state requires its own controlled substance permit, they must also obtain this permit as well, or apply for it, before registering with the DEA and receiving a DEA number.
If a resident does not have an X-waiver, buprenorphine prescriptions have to be signed by the attending, who must have their own X-waiver. If the attending in this situation does not have an X-waiver, the resident would not able to prescribe buprenorphine for the patient.
Updated January 2023
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