CurrentOptumPolicy N/A

Reimbursement guidance for substance use disorder and related behavioral health services

Defines codes and billing guidance for reimbursement of substance use disorder (SUD) services, behavioral health screening/assessment, medication treatment and dispensing, and related outpatient behavioral health encounters for Optum members.

Policy Summary

PayerOptum

PolicyReimbursement guidance for substance use disorder and related behavioral health services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing outpatient visits for SUD or behavioral health, document and submit the appropriate service code and applicable outpatient place of service or mental health provider/diagnosis as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70+listed CPT/HCPCS/Revenue/ICD-10 codes and variations

0906,0944,0945example SUD revenue codes

Z71.41,Z71.51SUD screening/assessment diagnosis codes

many POSoutpatient POS guidance

Coverage Criteria

Coverage criteria by code and setting

Payment for listed codes depends on whether the code requires a mental health provider, a diagnosis of substance use/drug overdose, and/or a specified Outpatient Place of Service (POS).

ALL of the following

Includes codes listed in the policy as payable without a mental health provider/diagnosis/POS when not otherwise specified (see coding tables).

ALL of the following

ANY of the following
- CPT 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99252-99255 (when visit is with a mental health provider or any diagnosis of substance use/drug overdose).
- Other outpatient/office and preventive codes requiring a mental health provider or SUD/drug overdose diagnosis: CPT 99202-99205, 99211-99215, 99242-99245, 99341-99350, 99381-99397, 99391-99397, 99401-99404, 99411-99412, 99483, 99492-99494, 99510; HCPCS and revenue codes listed for behavioral health outpatient services (see coding tables).

Policy Summary

PayerOptum

PolicyReimbursement guidance for substance use disorder and related behavioral health services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Codes and Billing Guidance

Behavioral health screening/assessment codesmixedCovered

CPT: 99408	Alcohol and/or substance abuse structured screening and brief intervention; 15-30 minutes
CPT: 99409	Alcohol and/or substance abuse structured screening and brief intervention; >30 minutes
HCPCS: G0396	Alcohol and/or substance misuse screening, 15 minutes
HCPCS: G0397	Alcohol and/or substance misuse counseling, 15 minutes
HCPCS: G0442	Annual alcohol misuse screening, non-face-to-face
HCPCS: G2011	Remote evaluation of recorded video and/or images
HCPCS: H0001	Alcohol and/or drug assessment
HCPCS: H0002	Behavioral health screening to determine need for early intervention services
HCPCS: H0031	Mental health assessment, by non-physician
HCPCS: H0049	Alcohol and/or drug screening (non-specific)

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Medication treatment and dispensing (AOD and OUD)mixedCovered

HCPCS: G0533	Medication administration for treatment of substance use disorder
HCPCS: G2069	OUD monthly office-based treatment (medication management)
HCPCS: G2067	OUD weekly non-drug service (specific)
HCPCS: G2068	OUD weekly non-drug service (specific)
HCPCS: G2073	Medication treatment service (ancillary)
HCPCS: H0020	Alcohol and/or drug detoxification inpatient
HCPCS: H0033	Medication assisted therapy, administration and monitoring
HCPCS: J0571	Buprenorphine, sublingual tablet
HCPCS: J0572	Buprenorphine, sublingual tablet, other strengths
HCPCS: J0573	Buprenorphine, buccal film

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Outpatient behavioral health and related servicesmixedCovered

CPT: 99202-99205	Office or other outpatient evaluation and management (new patient)
CPT: 99211-99215	Office or other outpatient evaluation and management (established patient)
CPT: 99221-99223	Initial hospital care
CPT: 99231-99233	Subsequent hospital care
CPT: 99238-99239	Hospital discharge day management
CPT: 99341-99350	Home visit new/established patient
CPT: 99381-99397	Preventive medicine new and established
CPT: 99401-99404	Preventive medicine counseling
CPT: 99411-99412	Group counseling
CPT: 99483	Assessment and care planning for cognitive impairment

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Provider Billing Actions and Requirements

Billing Rule

Outpatient visit and service code guidance — mental health provider, diagnosis, and POS required

Outpatient visits and related service codes require specific provider, diagnosis, and place-of-service documentation to bill correctly. Ensure a mental health provider or an active diagnosis of substance use/drug overdose is documented when billing the listed CPT/ED/Outpatient codes, and include the appropriate outpatient Place of Service (POS) code when required.

Affected CPT codes: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99252-99255
Required documentation: mental health provider (e.g., psychiatrist, psychologist, licensed clinical social worker) OR an active diagnosis of substance use/drug overdose on the claim/medical record
Place of Service: when billing outpatient services, include the appropriate outpatient POS code (e.g., POS 2, 10, 52, 53, 56, 57, 58) as applicable
Exceptions: Certain codes not listed above may not require a mental health provider, substance use/drug overdose diagnosis, or a specific outpatient POS — verify code-level guidance before billing

Definitions and Administrative Notes

inv-08: Outpatient Place of Service code mappings

POS code 03School; also mapped to 14, group home, 22 (on-campus outpatient hospital) in examples provided.

POS code 05Indian Health Service free-standing facility; includes mappings to mobile unit, custodial care facility, and other examples.

POS code 07Tribal 638 free-standing facility; includes temporary lodging, independent clinic, and other mappings.

POS code 09Prison/correctional facility; examples include walk-in retail clinic and federally qualified health center mappings.

POS code 11Office; also mapped to place of employment/worksite, public health clinic, and related mappings.

Additional POS examplesPOS 12 (Home, off-campus outpatient hospital, rural health clinic), POS 13 (Assisted living, urgent care, non-residential opioid treatment facility) and other outpatient POS mappings are listed in the policy.

inv-09: Trademark and administrative note

Trademark acknowledgementsHEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA); CPT is a registered trademark of the American Medical Association.

Payer final determinationThe payer will make the final determination regarding reimbursement upon receipt of a claim; submission of a claim with a code listed in this document is not a guarantee of payment.