Allowed and Paid Costs for Inpatient Opioid Treatment CPT Codes Analysis

Allowed and Paid Costs Inpatient vs. Outpatient Opioid Claims based on Procedure Codes Rate and Form Compliance Division Commissioner Vicki Schmidt Director Julie Holmes Anthony Depner Research Analyst 6/10/2025

Query Information The pulled data was based on two different types of code, CPT procedure codes and ICD-10 diagnosis codes. As this created a lot of different information to display, both types of codes will be represented in two different reports. This report with be based on the CPT procedure codes for opioid treatment. The information was also separated into inpatient treatment and outpatient treatment. 2020 through the third quarter of 2024 are the years of data queried. Each year had similar procedure codes used, with there being a few unique codes between. 2

All Inpatient CPT Codes H0010 Alcohol and/or drug services; sub-acute detoxification H0011 Alcohol and/or drug services; acute detoxification H0018 Behavioral health; short-term residential H0019 Behavioral health; long-term residential (Longer than 30 days), without room and board HZ2Z/HZ2ZZZ Detoxification services for substance abuse treatment T2048 Behavioral health; long-term residential (Longer than 30 days), with room and board 90791 Psychiatric evaluation of the patient 90832 Psychotherapy (16-37 minutes) 0DJ08Z Inspection of intestinal tract HZ3/HZ39/HZ39ZZZ Substance abuse treatment, individual counseling 3

All Inpatient CPT Codes (cont.) B211 Fluoroscopy of multiple coronary arteries 3E033N Introduction of analgesics, into peripheral vein 5A19 Respiratory Ventilation, single, nonmechanical 009U3ZX Drainage of Spinal Canal, Percutaneous HZ42ZZZ Group counseling for substance abuse treatment HZ49ZZZ Group counseling for substance abuse treatment HZ85 Medication management for substance abuse HZ81ZZZ Medication management for substance abuse HZ89ZZZ Medication management for substance abuse HZ95ZZ Pharmacotherapy for substance abuse GZHZZZZ Group Psychotherapy 4

All Inpatient CPT Codes (cont.) 110 Dermatophytosis 111 Dermatomycosis other and unspecified 114 Coccidioidomycosis 120 Schistosomiasis 124 Trichinosis 126 Ancylostomiasis and necatoriasis 128 Other and unspecified helminthiases 913 Superficial injury of elbow, forearm, and wrist 1002 Residential treatment, substance use disorders 5

Inpatient 2020 Allowed Averages Paid Averages $45,000.00 $40,000.00 $35,900.18 $38,214.00 AVERAGE ALLOWED ($) $40,000.00 $35,000.00 $11,093.06 AVERAGE PAID ($) $35,000.00 $30,000.00 $30,000.00 $4,589.85 $9,943.06 $4,986.26 $25,000.00 $4,128.23 $2,115.53 $3,526.07 $25,000.00 $2,600.67 $3,809.83 $20,000.00 $20,000.00 $8,616.67 $3,937.82 $3,120.00 $15,000.00 $15,000.00 $4,162.02 $2,894.72 $880.11 $2,894.72 $10,000.00 $6,502.02 $478.15 $10,000.00 $286.89 $1,476.53 $2,992.02 $5,000.00 $5,000.00 $873.44 $- $- N/A 3E033N 5A19 H0018 H0019 HZ2Z HZ2ZZZ HZ2ZZZZ HZ42ZZZ HZ49ZZZ HZ85 T2048 N/A 3E033N 5A19 H0018 H0019 HZ2Z HZ2ZZZ HZ2ZZZZ HZ42ZZZ HZ49ZZZ HZ85 T2048 Claim Counts 160 141 140 120 CLAIM COUNT 100 80 60 40 13 20 6 5 4 3 2 6 1 1 1 1 1 0 N/A 3E033N 5A19 H0018 H0019 HZ2Z HZ2ZZZ HZ2ZZZZ HZ42ZZZ HZ49ZZZ HZ85 T2048

Inpatient 2021 Allowed Averages Paid Averages $18,000.00 $16,000.00 $16,275.00 $14,422.50 AVERAGE ALLOWED ($) $16,000.00 $14,000.00 $4,590.72 AVERAGE PAID ($) $14,000.00 $12,000.00 $5,894.00 $12,000.00 $4,415.13 $1,679.18 $7,388.00 $3,752.13 $10,000.00 $1,632.00 $1,761.53 $8,820.00 $10,000.00 $8,000.00 $5,904.00 $6,441.60 $5,894.00 $8,000.00 $1,632.00 $6,000.00 $2,584.10 $6,000.00 $3,967.12 $3,477.60 $3,895.50 $3,403.50 $3,097.97 $4,000.00 $1,941.19 $4,000.00 $1,941.19 $1,071.57 $2,000.00 $597.69 $597.69 $597.65 $425.61 $2,000.00 $- $- N/A 90832 H0010 H0018 H0019 HZ2Z HZ2ZZZ HZ2ZZZZ HZ42ZZZ HZ81ZZZ HZ85 HZ85ZZZ HZ89ZZZ T2048 N/A 90832 H0010 H0018 H0019 HZ2Z HZ2ZZZ HZ2ZZZZ HZ42ZZZ HZ81ZZZ HZ85 HZ85ZZZ HZ89ZZZ T2048 Claim Counts 300 261 250 200 CLAIM COUNT 150 100 50 25 12 8 2 2 2 7 1 1 1 1 1 1 1 0 N/A 90832 H0010 H0018 H0019 HZ2Z HZ2ZZZ HZ2ZZZZ HZ42ZZZ HZ81ZZZ HZ85 HZ85ZZZ HZ89ZZZ T2048

Inpatient 2022 Allowed Averages Paid Averages $25,000.00 $25,000.00 $20,278.03 $20,278.03 AVERAGE ALLOWED ($) $20,000.00 $20,000.00 AVERAGE PAID ($) $4,616.03 $6,433.00 $15,000.00 $15,000.00 $5,126.41 $2,992.50 $7,952.96 $10,000.00 $10,000.00 $3,027.49 $4,177.81 $6,433.00 $6,209.05 $2,661.87 $3,063.75 $3,983.00 $3,294.21 $5,000.00 $5,000.00 $2,533.92 $- $- N/A 009U3ZX GZHZZZZ H0010 H0018 HZ2Z HZ2ZZZZ HZ46ZZZ N/A 009U3ZX GZHZZZZ H0010 H0018 HZ2Z HZ2ZZZZ HZ46ZZZ Claim Counts 400 357 350 300 CLAIM COUNT 250 200 150 100 27 26 50 8 7 8 1 1 1 0 N/A 009U3ZX GZHZZZZ H0010 H0018 HZ2Z HZ2ZZZZ HZ46ZZZ

Inpatient 2023 Allowed Averages Paid Averages $20,000.00 $20,000.00 $18,046.45 $18,046.45 $16,843.39 $16,843.39 $18,000.00 $18,000.00 $13,457.36 $5,399.18 AVERAGE ALLOWED ($) $6,433.47 $16,000.00 $16,000.00 $11,021.21 AVERAGE PAID ($) $2,262.75 $14,000.00 $14,000.00 $8,546.36 $5,642.72 $6,600.76 $7,053.64 $5,421.18 $12,000.00 $12,000.00 $5,999.09 $2,698.00 $7,583.69 $5,251.13 $10,000.00 $10,000.00 $6,120.80 $2,545.15 $8,000.00 $8,000.00 $3,504.10 $1,474.67 $1,474.67 $4,404.02 $4,299.67 $6,000.00 $6,000.00 $3,117.31 $2,542.40 $2,142.80 $4,000.00 $4,000.00 $1,902.12 $1,613.11 $988.41 $790.73 $2,000.00 $2,000.00 $- $- N/A 110 111 114 124 126 913 1002 H0010 H0011 H0018 H0019 HZ2Z HZ2ZZZZ HZ39 HZ39ZZZ N/A 110 111 114 124 126 913 1002 H0010 H0011 H0018 H0019 HZ2Z HZ2ZZZZ HZ39 HZ39ZZZ Claim Counts 400 337 350 300 CLAIM COUNT 250 180 200 119 150 100 50 10 9 8 5 3 3 2 2 1 1 1 1 1 0 9

Inpatient 2024 Q1 - Q3 Allowed Averages Paid Averages $11,152.62 $12,000.00 $12,000.00 $3,951.86 $10,110.42 $9,088.89 $5,098.14 AVERAGE ALLOWED($) $10,000.00 $10,000.00 $8,688.91 $8,368.19 $8,311.84 $8,311.84 AVERAGE PAID($) $8,165.68 $8,000.00 $8,000.00 $6,893.67 $6,069.61 $3,701.40 $6,000.00 $6,000.00 $2,731.52 $4,860.00 $2,069.35 $4,060.00 $4,000.45 $3,521.40 $3,155.31 $4,000.00 $4,000.00 $2,861.84 $1,735.42 $2,195.24 $1,489.04 $2,000.00 $2,000.00 $- $- NA 110 111 114 120 126 128 1002 H0010 H0018 HZ2Z HZ2ZZZZ NA 110 111 114 120 126 128 1002 H0010 H0018 HZ2Z HZ2ZZZZ Claim Counts 400 361 350 300 259 CLAIM COUNT 228 250 200 150 100 50 18 13 8 7 4 3 2 2 1 0 10

All Outpatient CPT codes 36415 Collecting a blood sample 80053 Comprehensive metabolic panel or CMP Test 80305 Presumptive drug test by any method 80307 Presumptive drug test via instrumented chemistry 90791 Psychiatric evaluation of the patient 96360 Catheter intravenously introduction for dehydration 96372 Injection of therapeutic, prophylactic, or diagnostic substance 96374 Administers of a single medication or other substance 11

All Outpatient CPT codes (cont.) 99202 New patient for office visit (15-29 minutes) 99203 New patient for office visit (30-22 minutes) 99212 Established patient for office visit (10-19 minutes) 99213 - Established patient for office visit (20-29 minutes) 99214 - Established patient for office visit (30-39 minutes) 99281 Lowest level emergency department visit 99283 Emergency department visit for evaluation (Low) 99284 - Emergency department visit for evaluation (Medium) 99285 - Emergency department visit for evaluation (High) 12

All Outpatient CPT codes (cont.) G0480 Drug Test (1-7 drug classes) H0015 Intensive outpatient (3 hours/day, 3 days/week) H0022 Intervention service (planned facilitation) H0035 Mental health partial hospitalization, less than 24 hours HZ33 Individual counseling for substance abuse J1650 Injection, enoxaparin sodium, 10 mg S0201 Partial hospitalization less than 24 hours S9475 Ambulatory setting substance abuse treatment S9480 Intensive outpatient psychiatric services 13

All Outpatient CPT codes (cont.) 250 Diabetes mellitus 258 Polyglandular dysfunction and related disorders 259 Other endocrine disorder 260 - Kwashiorkor 300 Anxiety, dissociative and somatoform disorders 301 Personality disorders 303 Alcohol dependence syndrome 305 Nondependent abuse of drugs 306 Physiological malfunction arising from mental factors 307 Special symptoms or syndromes not elsewhere classified 900 Injury to blood vessels of head and neck 906 Late effects of injuries to skin and subcutaneous tissues 14

Outpatient 2020 Allowed Averages Paid Averages $2,500.00 $2,000.00 $1,761.00 $2,111.00 $1,800.00 $1,312.50 AVERAGE ALLWOED ($) $1,312.50 $2,000.00 $1,600.00 AVERAGE PAID ($) $858.00 $1,400.00 $858.00 $1,500.00 $1,200.00 $380.63 $884.03 $1,092.25 $1,000.00 $648.77 $796.07 $1,000.00 $800.00 $600.00 $317.90 $380.63 $230.00 $352.39 $210.00 $500.00 $400.00 $200.00 $- $- N/A 80053 96360 H0015 H0035 S0201 S9475 S9480 None 80053 96360 H0015 H0035 S0201 S9475 S9480 Claim Counts 400 357 350 300 CLAIM COUNT 250 200 150 100 50 9 4 15 2 2 2 1 1 0 N/A 80053 96360 H0015 H0035 S0201 S9475 S9480

Outpatient 2021 Allowed Averages Paid Averages $3,571.00 $8,000.00 $7,000.00 $6,138.00 $6,820.00 AVERAGE ALLOWED ($) $7,000.00 $6,000.00 $1,683.44 AVERAGE PAID ($) $6,000.00 $5,000.00 $1,143.44 $1,404.33 $5,000.00 $1,632.77 $4,000.00 $2,856.80 $4,000.00 $1,327.66 $3,000.00 $286.44 $258.00 $3,000.00 $1,304.10 $343.48 $2,000.00 $122.20 $2,000.00 $745.98 $771.32 $679.52 $589.87 $1,000.00 $258.00 $1,000.00 $122.20 $- $- N/A 80307 99212 99281 99284 99285 H0015 H0035 J1650 S0201 None 80307 99212 99281 99284 99285 H0015 H0035 J1650 S0201 Claim Counts 426 450 400 350 300 CLAIM COUNT 250 200 150 100 50 6 4 4 3 16 2 1 1 1 1 0 N/A 80307 99212 99281 99284 99285 H0015 H0035 J1650 S0201

Outpatient 2022 Allowed Averages Paid Averages $2,361.00 $2,361.00 $2,500.00 $2,500.00 AVERAGE ALLOWED ($) $1,832.86 $1,812.00 $2,162.00 $2,000.00 $2,000.00 AVERAGE PAID ($) $1,653.37 $1,619.68 $1,564.94 $1,490.33 $1,500.00 $1,500.00 $1,228.97 $1,122.37 $1,018.03 $763.52 $761.01 $749.50 $1,000.00 $1,000.00 $682.06 $657.47 $430.87 $375.17 $375.17 $500.00 $500.00 $164.74 $164.74 $152.26 $152.26 $- $- N/A 80305 96361 96372 96374 99282 99283 99284 G0480 H0015 H0035 S0201 N/A 80305 96361 96372 96374 99282 99283 99284 G0480 H0015 H0035 S0201 Claim Counts 500 433 450 400 350 CLAIM COUNT 300 250 200 150 100 14 50 6 6 2 17 1 1 1 1 1 1 1 0 N/A 80305 96361 96372 96374 99282 99283 99284 G0480 H0015 H0035 S0201

Outpatient 2023 Allowed Averages $25,000.00 $21,140.51 $20,000.00 AVERAGE ALLOWED ($) $15,000.00 $1,589.20 $2,844.09 $1,399.45 $10,000.00 $7,850.52 $51.42 $911.22 $551.09 $758.59 $1,089.29 $2,812.25 $390.00 $1,608.29 $206.04 $348.49 $3,128.04 $3,073.50 $5,000.00 $342.88 $2,371.21 $2,179.44 $2,121.33 $1,273.79 $864.56 $850.00 $750.80 $731.08 $518.75 $200.58 $152.39 $92.00 $34.00 $- N/A 250 253 259 260 300 301 302 303 305 306 307 309 324 450 459 636 762 900 906 912 913 914 915 90791 96372 99284 H0015 H0035 H2036 S0201 Paid Averages $7,408.58 $8,000.00 $7,000.00 AVERAGE PAID ($) $6,000.00 $1,254.57 $4,607.84 $5,000.00 $145.00 $458.75 $1,863.44 $4,000.00 $2,962.83 $2,823.50 $1,135.00 $2,293.24 $3,000.00 $2,031.54 $458.15 $115.74 $1,545.24 $1,535.26 $109.32 $2,000.00 $280.67 $267.88 $1,089.20 $942.02 $31.42 $850.00 $554.72 $485.20 $481.20 $1,000.00 $174.54 $120.46 $117.84 $86.15 $22.51 $12.48 $- 18 N/A 250 253 259 260 300 301 302 303 305 306 307 309 324 450 459 636 762 900 906 912 913 914 915 90791 96372 99284 H0015 H0035 H2036 S0201

Outpatient 2023 (cont.) Claim Counts 450 384 400 350 300 CLAIM COUNT 250 200 150 100 74 45 35 31 50 19 19 17 16 15 15 11 7 6 6 6 3 2 2 2 2 1 1 1 1 1 1 1 1 1 1 0 19

Outpatient 2024 Q1 - Q3 Allowed Averages $5,000.00 $4,344.42 $4,000.00 $726.95 $1,594.70 $2,800.64 $2,116.67 $1,050.00 $2,542.90 $3,000.00 $2,293.72 $1,738.75 $483.17 $1,525.58 $2,000.00 $567.48 $1,372.40 $1,350.15 $222.40 $125.00 $1,026.00 $456.59 $479.46 $767.50 $737.97 $592.91 $1,000.00 $430.17 $374.77 $319.42 $134.64 $111.62 $90.63 $57.79 $34.28 $- N/A 250 258 259 260 300 301 303 305 306 307 450 900 906 912 913 914 915 74177 85027 90853 93005 99282 99285 H0015 H0035 H2036 Q9967 S0201 S9480 Average Allowed Paid Averages $5,000.00 $4,344.42 $1,786.00 $936.64 $4,000.00 $1,050.00 $1,250.96 $30.00 $3,000.00 $2,293.72 $2,277.18 $2,183.35 $218.99 $117.50 $1,662.50 $537.44 $1,525.58 $2,000.00 $213.98 $323.98 $552.73 $1,218.71 $434.57 $718.20 $713.35 $631.80 $1,000.00 $409.87 $341.98 $319.42 $271.71 $134.64 $99.12 $81.55 $57.79 $- N/A 250 258 259 260 300 301 303 305 306 307 450 900 906 912 913 914 915 74177 85027 90853 93005 99282 99285 H0015 H0035 H2036 Q9967 S0201 S9480 20 Average Paid

Outpatient 2024 Q1 - Q3 (cont.) Claim Counts 300 256 245 250 200 150 116 100 42 50 29 22 21 21 20 15 14 14 12 10 10 6 2 2 2 2 2 2 1 1 1 1 1 1 1 1 0 N/A 250 258 259 260 300 301 303 305 306 307 450 900 906 912 913 914 915 74177 85027 90853 93005 99282 99285 H0015 H0035 H2036 Q9967 S0201 S9480 CODE 21

Key Notes Many of the codes that have larger payment amounts often have very low number of claims. Often with these claims, there are more than one procedure going on at once, so it is all tied together in a singular claim. This helps explain the averages that are way above normal expected claim amounts. The most common CPT code was N/A . About 59.15% of all claims pulled did not have a CPT code associated with it. This is due to those claims having a diagnosis of some form of opioid abuse, use, or dependence but not having a procedure code associated for the diagnosis. The second most common inpatient code was 126 (ancylostomiasis and necatoriasis). The second most common outpatient code was H0015 (Intensive outpatient (3 hours/day, 3 days/week)). 22

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