Requirements for documenting buprenorphine therapy vary from state to state. You must obtain and review appropriate licensing regulations to assure that you are complying with all the requirements in your region.
Documentation requirements may include:
- The induction order
set and plan of care for starting and monitoring buprenorphine. - Evidence of the buprenorphine eligibility criteria. This may include lab results, physician review and sign-off of lab results, and other clinical documents. Evidence of eligibility will need to include all the elements required for the appropriate Current Procedural Terminology code.
See Sample Form: MAT Physician Progress Note
- Patient informed consent . This should include information about risks and benefits of the medication, alternative treatment methods, patient rights and responsibilities, program expectations, orientation material, fee agreements, and a therapeutic agreement.
Throughout the screening process, stress key points of the informed consent form and program expectations.
See Sample Form: Points to Make During Induction
See Sample Form: MAT Expectations
Documentation for patients who are pregnant and surgical patients
Organizations providing buprenorphine treatment to patients who are pregnant may need to complete additional documentation. As standard of best practice (and in Joint Commission accredited programs), buprenorphine prescribing physicians are required to document evidence that pregnant patients have received:
- A referral to substance use disorder treatment
- Education on the benefits of prenatal care
- Notification of their right to refuse the referral to treatment
See sample prenatal education and informed consent tool:
Prenatal Services and Well-Baby Care for Infants
Planning for labor and delivery and pain control in other surgical patients
Planning for labor and delivery and pain control in other surgical patients is an important part of documentation of buprenorphine treatment services.
See sample forms:
Pain Management Plan for OB Patients on Subutex (buprenorphine)
Related resources
- Optum Health: Examples of codes and documentation requirements:
- Optum E_M Quick Reference Table
Updated 10/16/20