Summary & Overview
HCPCS J0573: Buprenorphine/Naloxone Oral, >3 mg to ≤6 mg Buprenorphine
HCPCS Level II code J0573 designates an oral unit of buprenorphine/naloxone containing greater than 3 mg and up to 6 mg of buprenorphine. This formulation is a cornerstone medication for outpatient treatment of opioid use disorder, balancing opioid agonist effects with an antagonist to deter misuse. Nationally, accurate coding for this product affects pharmacy claim processing, access to medication-assisted treatment, and aggregation of utilization data that inform public health and payer policy.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find benchmarks and coverage context for how payers handle claims for this specific buprenorphine/naloxone strength, relevant policy considerations affecting prior authorization and reimbursement workflows, and clinical context describing the formulation and typical outpatient dispensing settings. The report organizes payer practices, common modifiers in use, and implications for billing workflows. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code J0573 represents a specific oral formulation of buprenorphine/naloxone, containing greater than 3 mg but less than or equal to 6 mg of buprenorphine per unit. This medication is used in the treatment of opioid use disorder as a partial opioid agonist combined with an opioid antagonist to reduce misuse and withdrawal symptoms.
Service type: Medication administration / outpatient prescription
Typical site of service: Outpatient pharmacy or clinic-based dispensing for outpatient treatment
Clinical & Coding Specifications
Clinical Context
A typical patient is a 28-year-old adult with opioid use disorder (OUD) presenting to an outpatient addiction medicine clinic for initiation or maintenance therapy. The patient reports cravings and has a history of prescription opioid or heroin use. After medical evaluation including review of withdrawal severity, medication history, and urine drug screen, the clinician prescribes buprenorphine/naloxone tablets with a dose in the range of greater than 3 mg and up to 6 mg of buprenorphine (J0573). The medication is dispensed by the outpatient pharmacy or administered as part of a monitored induction visit. Follow-up visits occur at regular intervals for assessment of treatment response, counseling, prescription refills, and coordination with behavioral health services. Typical documentation includes diagnosis of opioid use disorder, informed consent, medication reconciliation, treatment plan, and counseling notes. Typical site of service is outpatient ambulatory clinic or office-based treatment with pharmacy dispensing; occasional use in observation or emergency department settings for initiation before outpatient follow-up.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier | Use when no specific modifier applies to the claim for this drug service |