What should a MAT note include besides the dose?

Last use, current dose and whether they took it, cravings or withdrawal, naloxone in hand, toxicology if you got it, counseling or the referral, and a plan that matches today's risk. 'Continue buprenorphine' is a med list, not a visit.

Do I have to document naloxone at every MAT visit?

Document that they have it, that it was offered, or that they refused, and the date you last prescribed or replaced it. A one-time mention from intake is not a living safety plan.

Is a harm-reduction visit billable as MAT if I did not change the dose?

It can be, if you evaluated the disorder, managed the medication, and wrote a medically necessary plan. Distributing supplies without an assessment is not a psychiatric visit. Write what you did.

What should a MAT note include on a day the country is talking about overdose?

International Overdose Awareness Day does not change the billing rules. Last use, naloxone, the dose you sent, and the intervention you actually did still have to be in the chart.

International Overdose Awareness Day does not invent a new CPT code. It is a useful annoyance: if your MAT notes today are only a dose and “patient stable,” you are documenting a slogan, not a treatment.

I write these notes every week, and I still see the same holes after recoupment letters and record requests. Last use is missing. Naloxone is an intake checkbox from 2024. The UDS is “pending” for three months. Counseling is “encouraged.”

The visit, not the holiday

Write last use: what, when, how. “No use” needs a timeframe. Since Tuesday is different from since 2022.

Write the dose they are actually taking, not the dose you wish they were taking. If they ran out Friday and used fentanyl twice, that is the visit. The prescription you send might still be 16 mg. The note has to hold both facts.

Withdrawal, cravings, sedation, whether they can walk into work. If you billed an E/M, something in that list has to have required you.

Naloxone is a living line

Rextovy went over the counter this summer. That does not retire your job. OTC availability is not the same as “this person has a kit in the kitchen.” Ask. Write whether they have it, whether it expired, whether you sent another.

If they refuse, write the refusal. Do not skip the sentence because it feels preachy on a day every org is posting a purple ribbon.

Toxicology without theater

A UDS is a data point, not a verdict on the patient. If you collected one, say what you will do with it. If you did not, say why (stable, quarterly schedule, they declined, the cup was not in the office). “UDS pending” on six consecutive notes is a tell.

Inconsistent results need a response in the same note: closer follow-up, observed dosing, a conversation, a higher level of care. Silence is how diversion reviews get ugly. The MAT note requirements spell out the rest, including 42 CFR Part 2.

Harm reduction is not a substitute for an assessment

There is a loud fight this year about kits, pipes, and whether public health is “enabling.” Your chart is not a press release. You can hand someone naloxone and still write a medical note: opioid use disorder, severe, last use two days ago, buprenorphine 16 mg continued, counseling Thursday, return in a week because they missed two groups.

If the encounter was only a supply drop and a wave, it is not a med-management visit. Do not dress it up as one. If you did the clinical work, write the clinical work. The politics will be there tomorrow. The auditor will only have this page.

Questions I get

Do I mention Overdose Awareness Day in the note? Only if it changed the visit (they came because of an event, a family member died this week, you ran a group around it). Otherwise it is decoration.

What if they are on naltrexone, not buprenorphine? Last use still matters. So does whether they missed a dose and used, and whether naloxone is even relevant to the current picture. Do not copy a buprenorphine template onto Vivitrol and call it done.

Can an AI draft fix this? It can catch “naloxone not mentioned” if you ask it to. It cannot invent last use you did not elicit. If the visit never asked, the draft will be a tidy version of that failure.