MME / ORT — Risk Assessment Tool

Captures the risk assessment the LCD actually asks for, shows the frequency ceiling the MAC will pay to, and drafts the chart note that has to survive a post-payment audit.

Novitas L35006 First Coast L36393 CDC 2022 MME factors Webster ORT

Patient & provider

saved with each assessment

Ordering provider

Provider NPI

Patient first name

Patient last name

Date of birth

Sex (feeds ORT weighting)

Ethnicity

MRN

Phone

Address

Current opioid regimen

MME = modifier, not the driver

0 MME / day Below 50

Opioid Risk Tool — the validated instrument the LCD requires

0 pts

Sex (ORT weights differ)

Family history of substance abuse

Age 16–45

Personal history of substance abuse

History & psychological

Clinical modifiers

Any check escalates one tier

Chart note

Clinician reviews, edits, signs

Ordering clinician's rationale — required the tool will not generate a note without this Frequency this clinician is ordering

Copied

Complete the rationale and frequency fields. The note is built from what the clinician entered — the tool contributes the codified risk data, never the clinical judgment.

Risk resolution

Track A — ORT (primary)0

Low 0–3

Mod 4–7

High 8+

Track B — MME (modifier)0

<50

50–89

90+

Composite tier

Low

higher of A/B, then +1 if any modifier

Frequency ceiling

what the MAC will pay

Patient composite riskLOW

Test	Ceiling
Presumptive UDT 80305 / 80306 / 80307	12 / yr
Presumptive, documented SUD exception to the annual cap	≤3 / 7 days
Definitive UDT, chronic opioid therapy G0480–G0483, G0659	12 / yr
Presumptive, per date of service regardless of billing provider count	1

These are ceilings, not targets. A high tier does not entitle anyone to 12 tests. Every test below the ceiling still needs its own documented justification. Billing to the cap by default is the exact pattern that draws a post-payment audit.

Not covered — ever

Blanket orders · routine standing orders across a practice · specimen validity testing (pH, specific gravity, oxidants, creatinine) · two specimen types, same day, same analytes · testing for employment or medico-legal purposes · immunoassay used to "confirm" immunoassay

How it works

The data flow — and the one thing it deliberately refuses to do

Every arrow moves toward documentation. None of them moves toward an order. That boundary is the whole compliance argument.

INPUT

Opioid regimen

Drug, dose, frequency. CDC 2022 conversion factors produce total daily MME. Methadone uses tiered factors. Buprenorphine is excluded and flagged.

INPUT

Validated risk instrument

ORT, scored with sex-specific weights. This is the input the LCD names by function. It leads; MME does not.

LOGIC

Tier resolution

Composite = higher of the two tracks, escalated one tier by any clinical modifier. Shown as two visible tracks so the clinician can see why it landed where it landed.

REFERENCE

LCD ceiling lookup

Displays the maximum the MAC pays. Static reference data. It never multiplies tier by a number to produce a recommended order count.

OUTPUT

Chart note — not an order

The clinician types the rationale and the frequency. The tool assembles a signed narrative. No rationale, no note. This is the line you do not cross.