Summary & Overview
HCPCS Level II M1036: Adults Without 180 Days Continuous OUD Pharmacotherapy
HCPCS Level II code M1036 denotes adults who have not achieved at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder (OUD) without a gap exceeding seven days. This measure captures gaps in ongoing medication treatment that are associated with higher relapse and overdose risk, and it is relevant for clinical quality monitoring, program reporting, and payer performance metrics nationwide. Nationally, continuity of OUD pharmacotherapy is a policy and public health priority given the sustained opioid-related morbidity and mortality.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of what M1036 represents, how it applies across outpatient treatment settings, and why continuity measurement matters for care quality and payer programs. The publication summarizes benchmarks where available, highlights potential policy implications for quality measurement and care management, and provides clinical context on pharmacotherapy continuity for OUD.
Data limitations: Data not available in the input for associated taxonomies, specific ICD-10 diagnoses, related codes, and detailed payer-specific coverage rules. The content focuses on the code definition, service context, and national relevance.
Billing Code Overview
HCPCS Level II code M1036 identifies adults who have not had at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder (OUD) without a gap of more than seven days. This code describes a patient population characteristic used in monitoring medication continuity for OUD treatment.
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Service type: Measurement of pharmacotherapy continuity for OUD (assessment/quality measure)
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Typical site of service: Outpatient care settings where medication for OUD is prescribed or managed, including office-based treatment programs, addiction medicine clinics, and outpatient behavioral health facilities.
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Clinical & Coding Specifications
Clinical Context
A 34-year-old adult with opioid use disorder (OUD) presents to an outpatient addiction treatment clinic for initial initiation of pharmacotherapy. The patient reports intermittent prior use of buprenorphine prescribed months ago but has not maintained at least 180 days of continuous pharmacotherapy without a gap greater than seven days. The clinical workflow includes intake assessment, review of prior medication history and prescription fill records, screening for withdrawal severity, and selection of appropriate medication-assisted treatment (e.g., buprenorphine or methadone). A clinician (addiction medicine physician, psychiatrist, or certified nurse practitioner) documents medical necessity, discusses risks/benefits, obtains informed consent, and prescribes or arranges initiation of medication. Follow-up visits are scheduled within 1–2 weeks for dose adjustment and monitoring, and coordination with counseling and case management is arranged. Typical site of service is outpatient behavioral health/addiction clinic or office-based opioid treatment program; urgent care or hospital outpatient clinic may also initiate therapy when community follow-up is arranged.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work required to initiate therapy is substantially greater than typically required (extensive assessment, coordination, or counseling beyond usual time). |