Summary & Overview
HCPCS Level II J0575: Buprenorphine/Naloxone Oral >10 mg
HCPCS Level II code J0575 designates buprenorphine/naloxone oral formulations with more than 10 mg of buprenorphine per unit. This code matters nationally because it identifies a commonly used medication for opioid use disorder in outpatient and ambulatory settings, impacting pharmacy billing, payer coverage determinations, and programmatic monitoring of medication-assisted treatment. Payers in scope for this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will learn what J0575 represents clinically and operationally, which sites of service and care settings typically use it, and which major payers are covered in the discussion. The publication provides benchmarks and payer coverage context, summarizes relevant policy considerations affecting access and billing, and outlines clinical context for when higher-dose buprenorphine/naloxone formulations are relevant in treatment of opioid use disorder. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code J0575 represents buprenorphine/naloxone, oral, greater than 10 mg buprenorphine. This medication formulation is used in the treatment of opioid use disorder and is administered orally.
Service type: Medication administration / pharmacy-dispensed outpatient medication
Typical site of service: Outpatient pharmacies, clinic-based dispensing, and ambulatory care settings
Clinical & Coding Specifications
Clinical Context
A 36-year-old patient with opioid use disorder presents to an outpatient addiction medicine clinic for initiation and maintenance of medication-assisted therapy. The clinician prescribes a buprenorphine/naloxone oral formulation with total buprenorphine dose greater than 10 mg daily, consistent with stabilization dosing. The typical workflow includes: assessment of opioid use history, confirmation of withdrawal status or appropriate initiation protocol, prescription of J0575 for the medication dispensed by a pharmacy or administered in a clinic, counseling on medication adherence and naloxone access, and scheduling follow-up visits for dose adjustment and monitoring of treatment response and urine drug screening. Typical sites of service include outpatient clinic, behavioral health centers, and pharmacy dispensing for take-home therapy; occasional initiation may occur in ambulatory infusion or observation units when medically indicated.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — standard service | Use when no special circumstance applies to the medication claim |
22 |