Addiction treatment providers will be pleased to know that Virginia has expansive addiction treatment coverage under its Medicaid program, nicknamed Cardinal Care. In fact, Virginia created an entire program called ARTS - Addiction and Recovery Treatment Services - to manage the expanded access to residential and medical detox services for Medicaid patients in the state.
Between 2018 and 2019, researchers identified a nearly 80% increase in the number of Medicaid patients receiving addiction treatment services in Virginia. This ongoing stream of patients in need of SUD services keeps addiction treatment providers in Virginia very busy, but a solid understanding of the Medicaid system in Virginia is a must for success in the recovery business.
In this post, we’ll cover some of the most common CPT codes you’ll need to know in order to bill Medicaid for addiction treatment successfully in Virginia, as well as some of the limitations ARTS providers need to know about peer services, sober living homes and residential treatment in “Old Dominion.”
Billing Medicaid for addiction treatment services in Virginia
With over 45,600 Medicaid patients seeking addiction treatment services in Virginia in 2019 alone, there’s more than enough demand to support a robust behavioral health business in the state.
First, a little background on Medicaid in Virginia. Virginia medicaid is often referred to as “Cardinal Care.” It is administered by Managed Care Organizations (or MCOs) including Aetna Better Health, Anthem HealthKeepers Plus, Molina Healthcare, Sentara Community Plan, UnitedHealthCare Community Plan, and Acentra Health. If you encounter patients who need to renew or enroll in Medicaid for the first time in Virginia, you can direct them to the application page to get them started. Single patients with no children or spouses qualify for Medicaid if their annual income does not exceed $21,579. For a family of four, that figure jumps to $44,400.
What addiction treatment services are covered under Medicaid in Virginia?
According to the ARTS Billing Instructions, Chapter 5, the following levels of care and types of services are covered under Medicaid in Virginia:
ASAM Level 4
ASAM Levels 3.1, 3.3, 3.5 and 3.7
ASAM Level 2.1 and 2.5
ASAM Level 1
ASAM 0.5
In less technical terms, these levels of care include:
Medically managed intensive inpatient services
Residential inpatient services
Intensive outpatient and partial hospitalization programs
Outpatient services
Early intervention services
OTP or Opioid Treatment Programs
Office-based addiction treatment or OBAT
Substance use care coordination
Substance use case management services
What are some of the most common CPT billing codes Medicaid Billers use for addiction treatment in Virginia? What’s the reimbursement structure for Medicaid addiction treatment services in Virginia?
Addiction treatment generally involves a set number of options when it comes to CPT codes. Although every treatment plan is slightly different, you’ll frequently see the same procedure codes repeat themselves again and again. Individual counseling sessions, group sessions, medication administration - these services are the “bread and butter” of substance use treatment.
According to the Addiction and Recovery Treatment Services (ARTS) Reimbursement Structure, here’s some of the most common CPT codes you’ll need to use for addiction treatment billing in Virginia. We’ve also included the standard reimbursements you can expect for each procedure. Some entries also include helpful notes about details like idiosyncratic exclusions, limits or CPT code modifiers for specific populations.
H0006 Substance use case management - reimbursed at $243.00 per unit
T1012 Peer support services - individual - $13 per unit
S9445 Peer support services - group - $5.40 per unit (per 15 minutes)
H0015 or rev 0906 with H0015 - Intensive outpatient - $250.00 per day
S0201 or rev 0913 with S0201 - Partial hospitalization - $500.00 per day
H0014 - MAT day one induction for OUD or AUD - $140.00 per encounter, limit of 3 inductions per calendar year with a single provider. Each induction must be spaced 90 days apart from one another.
G9012 - Substance use care coordination - $243.00 per month
H0020 - Medication administration (MAT) - $8.00 per encounter
H0004 - SUD treatment services - individual counseling - $24.00 per 15 minutes
H0005 - SUD treatment services - group counseling or family therapy - $7.25 per 15 minutes
J3490 - Drugs unclassified injection (MAT) - depends on the drug and dose
S0109 - Methadone medication administration in clinic - $0.26 per unit
J0570 - Buprenorphine implant/Probuprenorphine medication administration in clinic - $1311.75 per each 6 months
J0571 - Oral buprenorphine medication administration in clinic - $1.00 per unit
J0572 - Buprenorphine/naloxone oral, less than 3mg, medication administration in clinic - $4.34 per unit
J0573 - Buprenorphine/naloxone oral, more than 3 mg but less than 6mg, medication administration in clinic - $7.76 per unit
J0574 - Buprenorphine/naloxone oral, more than 6 mg but less than 10mg, medication administration in clinic - $7.76 per unit
J0575 - Buprenorphine/naloxone oral, greater than 10mg, medication administration in clinic - $15.52 per unit
Q9991 - Sublocade, Buprenorphine XR 100 mg or less, medication administration in clinic, $1886.97 per unit
Q9992 - Sublocade, Buprenorphine XR greater than 100 mg, medication administration in clinic, $1886.97 per unit
J2310 - Naltrexone HCL, injection, medication administration in clinic, $9.54 per unit
J2315 - Naltrexone injection, depot form, 1mg, medication administration in clinic, $3.96 per unit
H2034 - Clinically managed low intensity residential services - $196.88 per day
H0010 or rev 1002 with modifier TG - Clinically managed, population-specific, high intensity residential services, $518.86 per diem if delivered in a residential treatment center and NOT a psychiatric unit or freestanding psychiatric hospital. Reimbursed at $460.89 per diem if delivered in a psychiatric unit or freestanding psychiatric hospital according to the psychiatric per diem rate. Adult facilities should use modifier HB while adolescent facilities should use modifier HA.
Are peer support services or peer recovery support services covered for Medicaid patients in Virginia?
Yes. Virginia Medicaid covers peer recovery support services. There are some rules about this service that providers should know, however. You can find all of these rules in Virginia’s Peer Recovery Support Service Supplement Manual.
You cannot render more than 4 hours of peer support services for any given patient (equal to 16 units of service) in a single calendar day.
ARTS peer recovery support services are capped at a total of 900 hours per patient.
ARTS peer recovery support services must begin within 30 days of the competition of the initial assessment for services.
Group peer support services must be rendered in groups of no more than 10 patients. Progress notes for each patient must be filed in each Medicaid member’s record in order to provide documentation for reimbursement for group-based services.
Peer support services cannot be reimbursed when they include any of the following activities: transportation, record-keeping, documentation, paperwork, volunteer services, household tasks like chores and grocery shopping, on-the-job training, case management, meals and breaks, outreach to potential clients, and room and board.
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