Md. Code Regs. 10.09.80.06

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.80.06 - Limitations

A. The Program under this chapter does not cover the following:

(1) Community-based substance use disorder services not specified in Regulation .04 of this chapter;

(2) Community-based substance use disorder services not approved by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law;

(3) Services not identified by the Department as medically necessary or listed in Regulation .05 of this chapter;

(4) Investigational and experimental drugs and procedures;

(5) Substance use disorder visits solely for the purpose of

(a) Prescribing medication;

(b) Administering medication;

(c) Drug or supply pick-up;

(d) Collecting laboratory specimens;

(e) Interpreting laboratory tests or panels; or

(f) Administering injections, unless the following are documented in the participant's medical record:

(i) Medical necessity; and

(ii) The participant's inability to take appropriate oral medications;

(6) Services that are provided in a hospital inpatient or outpatient setting or in an intermediate care facility for behavioral health;

(7) Services beyond the provider's scope of practice; and

(8) Services that are separately billed but included as part of another service;

(9) Buprenorphine induction and buprenorphine maintenance therapy services that are:

(a) Delivered by a participant's primary care provider which are the responsibility of the Managed Care Organization as specified in COMAR 10.09.70; or

(b) Delivered without a primary diagnosis of substance use disorder;

(10) Presumptive and definitive drug testing when billed by:

(a) An opioid treatment program;

(b) An intensive outpatient program; or

(c) A partial hospitalization program provider;

(11) Peer recovery support services that are not provided either in-person or via telehealth; and

(12) Services not authorized consistent with this chapter

B. Providers may not be reimbursed by the Program for:

(1) More than one comprehensive substance use disorder assessment for a participant per provider per 12-month period unless the patient was discharged from treatment with that provider for more than 30 days;

(2) More than one Level 1 group counseling session per day per participant;

(3) More than six Level 1 individual counseling units as measured in 15 minute increments per day per participant;

(4) More than four sessions of Level 2.1 Intensive Outpatient treatment per week;

(5) Level 1 group or individual counseling during the same week as a Level 2.1 Intensive Outpatient treatment or Level 2.5 Partial Hospitalization service unless the participant has been discharged from or admitted to a new level of care;

(6) Overlapping episodes of Level 2.1 Intensive Outpatient treatment and Level 2.5 Partial Hospitalization;

(7) Level 1 group or individual counseling during the same week as Level 1 group or individual counseling offered by another provider;

(8) Psychiatric day treatment service as described in COMAR 10.63.03.08 or an intensive outpatient mental health service on the same day as a Level 2.1 Intensive Outpatient program or Level 2.5 Partial Hospitalization program;

(9) Buprenorphine maintenance therapy delivered by an opioid treatment program or a BHA licensed substance use disorder treatment provider during the same week as Methadone Maintenance Therapy;

(10) Ambulatory withdrawal management during the same week as an opioid maintenance therapy, medication assisted treatment induction, or buprenorphine maintenance service;

(11) Medication management billed by an opioid treatment program or a BHA licensed substance use disorder treatment provider during the same days as medication assisted treatment induction;

(12) Completion of forms or reports;

(13) Services delivered by federally qualified health centers other than those billed using T-codes that may include the following delivered by two separate appropriately licensed providers:

(a) One T-code for mental health services per day -with associated mental health procedure code; and

(b) One T-code for substance use disorder services -with associated H-code per day;

(14) Services rendered but not appropriately documented to the level of service;

(15) Services rendered by mail;

(16) Services rendered by mail, telephone, or otherwise not one-to-one, in person;

(17) Broken or missed appointments;

(18) Travel to and from site of service; and

(19) Transportation costs.

C. In order to bill for an individual in Level 2.1 Intensive Outpatient treatment, the per diem session shall include a minimum of 2 hours. A maximum of 4 per diems may be billed per week.

D. In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a half day session shall include a minimum of 2 hours.

E. In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a full day session shall include a minimum of 6 hours.

F. The Department shall pay participating opioid treatment programs, per participant, per week provided the participant received ongoing opioid treatment medications and at least one face-to-face documented treatment service in the month for which the Program is billed.

G. In order for an opioid treatment program to bill for medication assisted treatment induction, the provider shall bill this service only in the first week of treatment per participant or in the first week of treatment after a break from treatment of at least 6 months.

H. In order for an opioid treatment program to bill for buprenorphine maintenance therapy, the provider shall bill this service per participant per week.

I. In order to bill for ambulatory withdrawal management, providers may bill up to 5 per diems during the detoxification episode if determined medically necessary by the Department.

J. Peer recovery support services may not be used to supplant the minimum billing requirements for:

(a) Level 2.1 Intensive Outpatient treatment as described in §C of this regulation;

(b) Level 2.5 Partial Hospitalization half day session as described in §D of this regulation;

(c) Level 2.5 Partial Hospitalization full day session as described in §E of this regulation; and

(d) Opioid treatment program services as described in §F of this regulation.

K. All drug screening lab claims submitted to the ASO by providers other than opioid treatment programs shall list the applicable substance use disorder diagnosis.

Md. Code Regs. 10.09.80.06

Regulations .06 adopted as an emergency provision effective January 1, 2010 (37:6 Md. R. 474); adopted permanently effective May 31, 2010 (37:11 Md. R. 765)
Regulation .06 amended effective 42:21 Md. R. 1302, eff.10/26/2015; amended effective 44:7 Md. R. 356, eff. 4/10/2017; amended effective 49:23 Md. R. 996, eff. 11/14/2022; amended effective 50:9 Md. R. 379, eff. 5/15/2023