Payer Rules: Office Based MAT Treatment (OBOT)

Office Based MAT Billing is currently only available for Office Based Opioid Treatment (OBOT) Medicare. This rule functions similarly to other Kipu Payer Rules for integrated billing and must be set up by a Super Admin. Before you begin, you must already have codes configured in your instance.

All elements of the process must be configured prior to adding an office-based MAT treatment to the patient chart. 

Required Permissions: You must be a Super Admin to view or make changes to payer rules.

Services

In order to bill for OBOT, you must first create a service.

1. To begin, click on your initials and then click Settings. 
   
2. Then click the Billing Audit Tool tab.

1. Next, click on Services.
2. Then click the New Service button.
   
3. When the New Service window opens, you will see the following fields.
4. Enter the service name and start date in their proper fields, then select Office Based MAT Service from the Classification drop-down. (All three of these fields are required, as indicated by the asterisk (*).
5. As you can see, fewer fields will appear in the window when you choose Office Based MAT Services.

6. The Claim Format field defaults to Professional. 

   

   1. Important: If you need to have institutional and professional OBOT services, you can either create one for each or create one and adjust it on the billing report.
7. Next, select the desired location or locations by clicking the boxes beside their names.
8. Then click OK.
9. The newly created service will appear on the Services tab alphabetically by name.
10. You can edit the service by clicking on the pencil icon or delete it by clicking on the red x.
11. The Edit Service window has the same information as the New Service window and can be edited in the same way.

Payer Rules 

Once your service is set up, you must create a payer rule for it. As with other payer rules, you will need to create payer rules for each individual payer (i.e., if you have seven different Medicare payers, you will need to create seven different payer rules).

For information on creating or editing MAT Billing Rules, click here.

1. From the Billing Audit Tool tab, choose Payer Rules.
2. Next, you'll either need to create a new payer rule or edit an existing one. Check out this article for instructions on setting up a new payer rule. 
3. Once the payer rule is created, add a new billing rule by clicking on the Add Billing Rule button.
4. Choose Office Based MAT from the Billing Rule Type drop-down.

Payer Rules: Medicare MAT Billing Type

Once you've selected Office Based MAT billing, you have two MAT Billing Type Options. Medicare is the first option.

1. In your Billing Rule, select Medicare (Duration) from the MAT Billing Type drop-down.

2. The grayed-out fields (Provider Type, Billing Period, and both dates of service) cannot be edited from their default states. Select the service you created from the Service drop-down. All fields with asterisks (*) are required. 

   

   1. Note: If your facility only has one OBOT service, it will already be selected.

3. Next, choose the initial month code from the drop-down. This code will be billed when services are provided that last from 70-120 minutes in the first month. 

   

   1. Important: Codes must be set up prior to creating billing rules. For more information on setting up codes, click here.
4. Then choose the subsequent month code from the drop-down. This code will be billed when services are provided that last from 60-120 minutes in any month following the first.
   
5. Use the Add-on Code field to select the code that will be used for each additional 30 minutes of service exceeding the first 120 minutes of service. This code will generate a second line item
   

Payer Rules: Commercial MAT Billing Type

Once you've selected Office Based MAT billing, you have two MAT Billing Type Options. Commercial (Services) is the second option.

1. Select Commercial (Services) from the MAT Billing Type drop-down.

2. The grayed-out fields (Provider Type, Billing Period, and Date of Service) cannot be edited from their default states. Select the service you created from the Service drop-down. All fields with asterisks (*) are required.

   

   • Note: If your facility only has one OBOT service, it will already be selected.

3. The Transmit Individual Services box allows you to indicate that the payer requires proof of services. This option works for Labs Requisitions as well. 

   

   • When this checkbox is enabled, the expanded view of billing items in reports and patient charts will have an information icon to quickly identify OBOT items which will be included in transmission.
4. Select the desired code from the Partial Month Code drop-down, or type it in the field.
5. Minimum Required Services bundles based on the number of minimum required services (rather than the duration as in the Medicare option) entered in this field. This field defaults to 1, but you can change it as needed.

Included Codes and Completing the Billing Rule

Regardless of whether you have chosen Commercial or Medicare as the MAT Billing Type, the Included Codes section of the Billing Rule remains the same.

1. Add at least one code in the Included Codes field for the ancillary service(s) that you want the billing report for the OBOT monthly bundle to include. The code, or codes, entered here will prompt the payer rule to bill for OBOT and must be added to an evaluation or other ancillary service.
2. You can either type the code number into the field or select the desired code from the drop-down.
3. Once the billing rule is completed, click Update to save it.

Per Patient Workflow

Once you have created the service and added the payer rule, you can add the service to the patient chart.

1. To begin, navigate to the Information tab of the desired patient.
2. Then scroll down to the Utilization Reviews section and click the Add Service review button.
3. The Service Authorization window has a number of required fields indicated with an asterisk (*). For a more thorough explanation of all fields, check out this article.

• Start Date: Enter a start date in this field. The start date determines when the patient is considered an OBOT patient for billing and is a required field. For example, if the authorization starts in May but the first service isn’t performed until June, all June services will bundle under the subsequent month code, not the initial month code.  
• Status: Select a status for authorization. The billing integration only recognizes authorizations with a status of Approved or Denied.
• Service: Select the OBOT service you created earlier from this drop-down. This field is required.
• Click Save Authorization.
• The saved service review appears as follows.

Evaluations and Ancillary Services

Next, create an evaluation or other billable, ancillary service that includes one or more of the codes added to the billing rule and make sure it is enabled. Click here for instructions on creating evaluations, and here for instructions on making them billable. 

Once you have created your service, add it to the patient's chart as you would any other evaluation. Check out our article on adding forms for more information.

Keep the following requirements in mind:

• All evaluations must be billable and ancillary
• When durations do not meet the minimum, the service will be unbundled
• When durations meet the minimum, the services will be bundled and show the code selected on the payer rule

Billing

Bundled for Previous Month

The final step of the process is to bill for the office based MAT treatment you have created. Keep in mind that If you don’t meet the minimum, within the month, it will undo the bundling.  

1. In the patient's chart, begin by clicking on the Billing tab. By default, you'll land on the Billable Items subtab.
2. Click on the + sign beside the desired item.
3. As you can see, the evaluation shows that the duration met the 70-minute criteria set in the initial month code.
4. If the duration set in the evaluation exceeds the first 120 minutes of service, the add-on code will appear.
5. If you are billing for any subsequent months following the date in the Service Review, you will see that code.

Bundled for Current Month

The application will still run all bundling logic for OBOT services performed over the current month. The blinking red dot will remind you that transmission is disabled until the month is completed.

When you hover over the dot, it will display the following message.

Commercial (Services)

If you selected Commercial (Services), the Billable item will appear as follows.