CurrentOptumPolicy N/A

MOUD-related assessment, induction, stabilization, and maintenance billing codes

Defines procedure codes, services, unit/session guidance, authorization requirements, and fee schedule references for medication for opioid use disorder (MOUD) related visits (assessment, induction/taper, post‑induction stabilization, maintenance) for Optum payment processing.

Policy Summary

PayerOptum

PolicyMOUD-related assessment, induction, stabilization, and maintenance billing codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill assessment, induction, stabilization, and maintenance visits per listed CPT codes and fee schedule; no prior authorization required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 sessionAssessment units

up to 12Induction observation limit

12Stabilization sessions (avg)

1/moMaintenance frequency

q4wInjectable frequency

Coverage Summary

Coverage applies to assessment, induction/taper, post‑induction stabilization, and maintenance services as specified below; prior authorization is not required for these services.

ALL of the following

Assessment & Treatment Planning
- Service: Diagnostic interview (CPT 90792).# of units per protocol = 1 session
  Use when patient is evaluated and MOUD is not started on that date.
- Authorization required: No.
Initial Induction / Medically Managed Taper

Policy Summary

PayerOptum

PolicyMOUD-related assessment, induction, stabilization, and maintenance billing codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill assessment, induction, stabilization, and maintenance visits per listed CPT codes and fee schedule; no prior authorization required.

SourceLink

On This Page

Billing Codes and Units

Assessment CPT CodesCPTCovered

90792

Assessment & Treatment Planning, Diagnostic Interview

Initial Induction / Taper CPT CodesCPTCovered

99205	Initial Induction — new patient visit (60-74 min); oral medication administration; cannot bill same day as 90792
99417	Time add-on per additional 15 minutes (used for additional observation time, up to 12 units)

Stabilization / Maintenance CPT CodesCPTCovered

99215	Established patient visit (40-54 min)
99212-99214	Maintenance visits (established patient evaluation/management codes)
90833	Psychotherapy with medication management, add-on (use when clinically indicated)
90836	Psychotherapy with medication management, 45 minutes (use when clinically indicated)

Injectable Medication CPT CodesCPTCovered

96372

Therapeutic, prophylactic, or diagnostic injection; used for injectable naltrexone/Sublocade as clinically indicated

inv-06: Additional observation time limit

LimitUp to 12 units of additional observation time (15‑minute increments)

ContextApplies to Initial Induction or Medically Managed Taper for oral medication administration

Billing noteUse 99417 as time add‑on per additional 15 minutes

inv-07: Maintenance frequency

FrequencyMonthly (1 session per month)

Applies toMaintenance medication management visits

Injectable optionInjectable naltrexone/Sublocade: 1 injection every 4 weeks when clinically indicated

Provider Billing & Action Guidance

Documentation Required

Assessment & Treatment Planning — Diagnostic Interview

Assessment & Treatment Planning (Diagnostic Interview) is covered without prior authorization. Bill CPT 90792 for one diagnostic interview session; reimbursement follows the existing MD/PA/NP fee schedule. Use 90792 when the patient is evaluated and MOUD is not started on that date.

Billing Rule

Initial Induction / Medically Managed Taper — Oral Medication

Initial induction or medically managed taper involving oral medication administration is covered without prior authorization. Bill 99205 (or 99215 with 99417 time add‑ons) for one session and allow up to 12 additional 15‑minute observation units as needed; reimbursement per existing MD fee schedule.

Primary CPT codes: 99205 or 99215 with 99417 for additional 15‑minute increments
Units per protocol: 1 session plus up to 12 observation time units (15‑minute increments)
Cannot bill 99205 on same day as 90792

Billing Rule

Post Induction Stabilization / Medically Managed Taper

Post‑induction stabilization or medically managed taper (medication management and individual therapy as indicated) is covered without prior authorization. Frequency averages 12 sessions; induction period may be 1–3 sessions per week for up to 3 months and psychotherapy add‑ons (90833, 90836) may be used when clinically indicated; rates follow the existing MD fee schedule.

CPT range for visits: 99212–99214 (established patient visits e.g., 99215 for 40–54 min)
Psychotherapy with med‑management add‑ons: 90833 or 90836 when clinically indicated
Average number of sessions: 12; induction frequency 1–3 sessions/week up to 3 months

Billing Rule

Maintenance — Monthly Medication Management

Maintenance medication management is covered without prior authorization and is expected monthly (one session per month). Injectable naltrexone/Sublocade may be billed as 96372 as clinically indicated; reimbursement follows the existing MD fee schedule.

CPT codes for maintenance visits: 99212–99214
Injectable formulations (naltrexone/Sublocade): bill 96372; typical injection interval one every 4 weeks

Key Definitions

inv-12: Assessment & Treatment Planning — Diagnostic Interview

ServiceDiagnostic Interview

CPT code90792

AuthorizationNo prior authorization required

Units per protocol1 session

RateRate on existing MD/PA/NP fee schedule

inv-13: Initial Induction or Medically Managed Taper — Oral medication administration for induction/taper

ServiceOral medication administration for induction or medically managed taper

CPT codes99205 or 99215 with 99417 as time add‑on

Units per protocol1 session plus up to 12 additional 15‑minute observation units

AuthorizationNo prior authorization required

RateRate on existing MD fee schedule

inv-14: Post Induction Stabilization — Medication management with optional individual therapy; may include psychotherapy add‑ons when clinically indicated

ServiceMedication management with optional individual therapy; psychotherapy add‑ons when clinically indicated

CPT codes99212–99215; add‑on psychotherapy codes 90833 or 90836 when indicated

SessionsAverage 12 sessions; 1–3 sessions/week up to 3 months for induction

AuthorizationNo prior authorization required

RateRate on existing MD fee schedule

inv-15: Maintenance — Monthly medication management visits; may include injectable formulations every 4 weeks

ServiceMonthly medication management visits

CPT codes99212–99214 for visits; 96372 for injectable naltrexone/Sublocade as clinically indicated

Frequency1 session per month; injectable formulations typically every 4 weeks

AuthorizationNo prior authorization required

RateRate on existing MD fee schedule