Summary & Overview
HCPCS J0574: Buprenorphine/Naloxone Oral, >6 mg to ≤10 mg Buprenorphine
HCPCS Level II code J0574 denotes the oral combination product buprenorphine/naloxone with a buprenorphine component greater than 6 mg and up to 10 mg. Nationally, this code captures a commonly prescribed formulation for medication-assisted treatment of opioid use disorder, an area of ongoing public health and payer attention. Accurate coding of J0574 supports consistent benefits adjudication, pharmacy claims processing, and population-level tracking of treatment utilization.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical context, typical sites of service, and the kinds of benchmarks and coverage considerations payers commonly assess for opioid use disorder medications. The publication also outlines where to find information on billing practices, common modifiers used in pharmacy and ambulatory billing, and how J0574 relates to other dosage-specific HCPCS codes.
This summary is intended for coding professionals, revenue cycle staff, and policy analysts seeking a national perspective on how this medication code is represented in claims and reimbursement frameworks. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code J0574 represents buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg buprenorphine. This medication combination is used in the treatment of opioid use disorder and is furnished as an oral formulation.
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Service type: Medication administration/supply for opioid dependence treatment
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Typical site of service: Outpatient pharmacies and ambulatory care settings where prescription medications are dispensed or administered orally
Clinical & Coding Specifications
Clinical Context
A 34-year-old patient with moderate to severe opioid use disorder presents to an outpatient medication-assisted treatment clinic for initiation or continuation of combined buprenorphine/naloxone therapy. The clinician prescribes an oral formulation containing more than 6 mg but less than or equal to 10 mg of buprenorphine per dose, billed as J0574. The clinical workflow includes verification of diagnosis and prior treatment, review of current opioid use and withdrawal status, evaluation for contraindications, counseling on medication administration and naloxone availability, baseline vitals and urine drug screen as indicated, electronic prescription and dispensing at an enrolled pharmacy, and scheduled follow-up visits for dose adjustment, counseling, and monitoring. Typical sites of service are outpatient behavioral health clinics, office-based opioid treatment (OBOT) programs, community health centers, and ambulatory substance use disorder treatment programs. This medication is used for induction, stabilization, or maintenance phases of treatment for opioid dependence and may be part of a comprehensive care plan including behavioral therapy and case management.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | When additional work or complexity is documented for services associated with treatment coordination or complex counseling beyond typical scope |