Updated APG Billing Guidance for Hepatitis C Virus (HCV) Treatment in Part 822 OASAS Certified Outpatient Programs (Clinic, Opioid Treatment Programs, Outpatient Rehab and Comprehensive Outpatient Programs)
IMPACTED PLANS: Medicaid, HIV SNP, HARP
TO: OASAS Providers
Dear MetroPlusHealth Provider,
The Department of Health and Office of Addiction and Services and Supports (OASAS) has released updated APG Billing Guidance for Hepatitis C Virus (HCV) treatment in OASAS Certified Outpatient Programs (Clinic, OTP, and Comprehensive Outpatient Programs) for the impacted set of services outlined below, effective Jan 1, 2025.
- Physical Health – Evaluation & Management (E/M) Services
- Hepatitis A and/or Hepatitis B Vaccines
- Preventive Counseling Services
- Directly Observed Therapy (DOT)
E&M Procedure Codes for Physical Health Claims for HCV Related E/M Services:
| CPT Code | Description |
|---|---|
| 99202 – 99205 | New Patient, Evaluation and Management (E&M) |
| 99211 – 99215 | Existing Patient, Evaluation and Management (E&M) |
| 99382 – 99387 | New Patient, Physical Exam |
| 99392 – 99397 | Existing Patient, Physical Exam |
*Physical Health Rate Codes:
| Setting | Region | PH Rate Code | APG Number |
|---|---|---|---|
| Freestanding OTPs | Downstate | 1471 | 636 |
| Hospital Based OTPs | Downstate | 1555 | 636 |
Notes:
*Physical Health Rate code for OTP and IOS OTP are the same.
HCV Treatment falls under Physical Health E&M Services. If billed on the same date of service, an E/M visit can be reimbursed separately from behavioral health claims when HCV is the reason for the visit.
Diagnosis (Dx) Codes for HCV Treatment Billing:
- Use as Primary Dx Code when HCV is the reason for the visit.
| Diagnosis Code | Description |
|---|---|
| B1710 | Acute Hepatitis C without hepatic coma |
| B182 | Chronic viral Hepatitis C |
| B1920 | Unspecified viral Hepatitis C without hepatic coma |
Note: If these Dx codes are primary on the claim and an E/M code is included, the claim will generate APG 636 – Hepatitis without Coma.
Hepatitis A and/or B Vaccine Billing Guidance for OTP services includes:
| CPT Code | Description |
|---|---|
| 90746 | Hepatitis B Vaccine, Adult Dosage, 3 Dose Schedule (IM Use) |
| 90636 | Hepatitis A & Hepatitis B Vaccine, Adult Dosage (IM Use) |
| 90632 | Hepatitis A Vaccine, Adult Dosage (IM Use) |
Note: To be properly reimbursed, the claim line for the vaccine must include the provider’s actual cost in the charges field. Also, we will require an invoice to adjudicate these claims. If sending a paper claim, please include the invoice. If sending an electronic claim, we will pend the claim and request an invoice which should be faxed to 212-908-8789 with a cover sheet indicating claim number, member name and member ID so we can match your invoice to the claim.
Billing Codes for Preventive Counseling:
| CPT Code | Description | Units Limit |
|---|---|---|
| 99401 | Preventive Counseling | 1 |
| 99402 | Preventive Counseling | 1 |
| 99403 | Preventive Counseling | 1 |
| 99404 | Preventive Counseling | 1 |
| 99411 | Group Preventive Counseling | 1 |
| 99412 | Group Preventive Counseling | 1 |
Note: Preventive Counseling billed separately from E/M services must be distinct and well-documented, and claims must list a Medicaid enrolled practitioner as the rendering provider.
Billing Codes and Criteria for DOT Services:
| Setting</tdh | Region | HCPCS Code | Rate Code | APG Weight |
|---|---|---|---|---|
| Freestanding | Downstate | H0033/H0020 | 1564 or 1471 | 0.1179 |
| Hospital | Downstate | H0033/H0020 | 1567 or 1555 | 0.1179 |
- Billing Criteria for H0033/H0020
- H0033 can be billed twice per visit if the patient receives buprenorphine and another oral medication requiring DOT.
- H0033 is reimbursable under both Behavioral Health (BH) and Medical Visit rate codes.
- H0033 is reimbursable under any rate code.
- H0020 is only for methadone and cannot be used for HCV medications
Please refer to the OASAS APG Manual for State guidance and more information.
If you have any questions regarding this memo, please contact MetroPlusHealth at [email protected].