BILLING AND CODING FOR OUTPATIENT
SCREENING SUBSTANCE ABUSE
History/Background DRAFT 8/18/08
The outpatient clinic sites that have been working with WIPHL to implement outpatient screening for substance abuse are supporting the costs associated with this screening and intervention through grant funding from SAMHSA. A main objective of the SBIRT initative is to determine ways to support long term sustainability of the screening mechanism, once the grant funding is over. Clinics and practitioners in other outpatient settings may eventually conclude that offering alcohol and substance abuse screening services is a cost effective and necessary component of an outpatient visit; howver, it is recognized that some assistance with the cost of providing such screening is a key strategy to promote widespread implementation of this practice. Hence the importance of identifying compliant strategies within existing billing and coding systems is critical.
Status of Billing Recognition
WIPHL staff is working actively on changes within the Medicare and Medicaid programs to more directly recognize the costs of providing the screening and brief intervention services. For purposes of Medicare and Medicaid, this involves putting in place procedure codes with appropriate diagnosis codes to allow for processing of the substance abuse screening service and the services of the health educator. It is anticipated that, once the public programs are on board, private payors will follow suit. These policy changes are in various stages of implementation and will continue to unfold over the upcoming months.
In the interim, providers must work with existing procedure codes and billing protocols which accurately represent the screening and brief intervention services provides to patients. Thus, until further progress is made on billing policy change for screening and brief intervention services, this may necessitate setting up the screening and intervention process in certain ways so as to be compliant with existing billing protocols.
Please note - it is not clear under current billing regulations whether a substance abuse screening which results in no finding of substance abuse or a risk of substance abuse can be appropriately billed under existing billing protocols.
Issues
There are a number of issues that must be taken into consideration in billing for screening of outpatient alcohol and substance abuse:
1) Medicare and Medicaid typically pay for services provided only by credentialed providers. Special rules apply for services provided by ancillary providers – normally they must be delivered under the direct supervision of a credentialed provider and pursuant to a physician’s plan of care. Since health educators are not recognized as a credentialed provider, they would fall under these rules. In order to compliantly bill for the screening or brief intervention service provided by the health educator, careful attention must be paid to the process being used in the clinic setting to insure appropriate involvement by the physician and documentation of that involvement.
2) Both the Medicare and Medicaid programs restrict the ability to bill for multiple provider encounters on the same day. Thus, careful attention must be paid to billing for the services of a health educator and a physician for services provided on the same day. In particular, the programs will not recognize billing for more than one evaluation and management (E&M) visit on the same day.
3) Both the Medicare and Medicaid programs require that the provider’s billing practice must be consistent between their programs and private pay patients. As a example, a provider may not choose to bill only Medicare patients for outpatient substance abuse screening services, but not private pay patients.
4) There is understandable concern about the potential for the billing process to reveal sensitive health information about a patient that could have adverse consequences for other aspects of the patient’s life, i.e insurability and employability. Consequently, while appropriate diagnosis and procedure codes must be used to navigate payor billing systems, the selection and use of diagnosis codes is particularly important. To the extent the use of a code may reveal a sensitive diagnosis to a third party, the patient may need to be notified of this potential. The codes suggested in the charts below are intended to address this concern.
5) As always, generally accepted principles of coding dictate that the needs of the patient and the actual service provided to the patient be determinative of the coding approach selected.
Suggested Billing Protocols under Current Regulations
a) Medicare – Traditionally, the Medicare program has not paid for screening services without specific statutory or regulatory authorization; thus such authorization is currently being pursued through the policy making process. CMS has recognized this issue and has issued guidance to providers on how to proceed in the interim.
For calendar year 2008, a CPT editorial panel created two new CPT codes for reporting alcohol and/or abuse screening; however, Congress has yet to enact specific statutory authority to activate these codes. This is consistent with Medicare’s traditional practice to pay only for “treatment of a medically approved condition” with screenings or diagnostic procedures required to be authorized through Congressional action, (other examples being mandates for mammograms or prostate screenings). See CMS transmittal guidance document for Medicare contractors relating to the physician fee schedule (PFS) at (http://www.cms.hhs.gov/transmittals/downloads/R1423CP.pdf with a shorter summary to be found at http://www.cms.hhs.gov/ContractorLearningResources/downloads/JA5895.pdf)
Because statutory authority continues to pend, to address this issue in the interim, CMS created two parallel HCPCS G-Codes G0396 and G0397. These codes allow for proper reporting and payment for structured assessment and intervention services for alcohol and substance abuse that are not provided as screening services, but in the context of the diagnosis or treatment of an illness or injury.
Note that under this protocol, it appears that a screening which results in no finding can not be billed at this time. It may also be important to time the interaction of the patient with the health educator so that the physician has had a chance to make a diagnosis or determine a plan of care.
For the present time, providers should utilize the following billing protocols for assessment and intervention services provided to Medicare patients:
Assessment and Intervention Services for Substance Abuse (do chart form)
Diagnosis Code Procedure Code Provider Rate Modifier
Allowed Allowed
G0396 Insert $29.42 AQ HPSA
Must be performed (15-30 min)
in context of illness
or injury G0397 Insert $57.69 AQ HPSA
(>30 min)
Future: Once Congress has acted to authorize payment for screening services for patients without a diagnosis or suspected diagnosis, providers may utilize the following billing protocol for screening services provided to Medicare patients:
Screening for Substance Abuse
Diagnosis Code Procedure Code Provider Rate Modifier
TBD CPT 99408 Insert TBD AQ HPSA
(15-30 min)
CPT 99409 Insert TBD AQ HPSA
(>30 min)
Documentation Requirements for Medicare (insert)
BadgerCare +
Wisconsin’s BadgerCare Plus program, effective February of 2008, provides benefits for substance abuse screening to women with verified pregnancies.
(insert link to DHFS BadgerCare + Update 2008-04 dated January 08)
The benefit has two components:
1) Screening for substance abuse problems
2) Brief preventive substance abuse interventions for pregnant women identified as being at risk
(Note: coverage is also provided for screening and brief preventive counseling for mental health issues which are described in the Update.)
Providers are required to use an in-depth evidence based tool to identify pregnant women at risk; however there is no requirement to use a specific screening tool. The screening is limited to one unit of service per member per pregnancy. Substance abuse intervention services are limited to 16 units per member per pregnancy. For women identified to be at risk, brief preventive substance abuse intervention services are also covered. While providers are expected to use effective strategies for the intervention, DHFS does not endorse a specific approach. However, the SBIRT protocols available through the US DHHS are acknowledged by DHFS as an effective treatment strategy. (link - sbirt.samhsa.gov/about.htm)
To implement these benefits, two new HCPCS procedure codes have been identified under BadgerCare+. H0002 with the modifier HF is to be used for substance abuse screening, while H0004 with the modifier HF is to be used for substance abuse intervention services.
Allowable screening, counseling and intervention services must be provided by a certified or licensed health care professional, or by an individual under the direction of a licensed health care professional. Individuals who are not licensed health care professionals must have appropriate training or combination of training and work experience to administer any of these services.
Providers should utilize the following billing protocol for these services: (do in chart form)
Diagnosis code Procedure Code Max Allowable Fee Modifier Co-Pay
V28.9 H0002 HF $35 Peds None
(Unspecified Substance HPSA
Antenatal Abuse Screening
Screening)
V65.4 H0004 HF Varies Peds None
(Other Counseling Substance by HPSA
Not Specified) Abuse Intervention Provider
(see link)
Note: BadgerCare + HMO’s are required to provide at least the same benefits as those provided under fee for service arrangements.
Documentation Requirements for Medicaid BadgerCare+
The provider must document in the member’s file that the member was pregnant on the date of service, and must keep a copy of the completed screening tool. If someone other than a certified or licensed health care professional provides the services, the provider must keep documents concerning that individual’s education, training and supervision. Additional documentation requirements can be found in the Wisconsin Medicaid All-Provider Handbook (insert link)
Services to Wisconsin Medicaid Members – Other than Pregnant Women
While Wisconsin’s Medicaid program does pay for certain screening or diagnostic procedures for alcohol and substance abuse screening in an outpatient setting, it does not currently have a mechanism to directly recognize and pay for an outpatient screening done by a health educator. However, the program will pay for services provided by an ancillary provider, including a health educator, if they are performed under the supervision of a physician. Services performed in this manner must be billed using the physician’s billing number; however, the Medicaid program will not pay for two visits on the same day under the same provider number. Therefore, each clinic or outpatient setting should determine, based on its staffing and scheduling practices, what approach would work best to provide substance abuse screening services to its patients. It is anticipated that in the future some legislative or regulatory changes will be made within the MA program to more directly recognize payment for health educator screening services. In the meantime, one of the approaches below should be considered while legislative or regulatory changes are pursued within the MA program to more directly recognize these costs.
1) Health Educator Visit
Stand Alone or with Same Day Visit with
Non-Supervising Provider
Patient sees health educator in the clinic setting for an alcohol and substance abuse screening but has no other visit scheduled at the clinic for that day. Because the health educator is not a credentialed provider, the health educator is treated as an ancillary provider and must be working under the direct, on-site supervision of a credentialed provider. Claims for services provided by the health educator must be submitted under the supervising physician’s Medicaid provider number using the lowest appropriate level office of outpatient visit procedure code or other appropriate CPT code for the procedure performed. Coverage is limited to procedure codes 99211 or 99212, as appropriate.
With Rate
Diagnosis Code Procedure Code Provider Rate Modifier
V 82.9 99211 Health 12.07 TJ Peds 13.00
Educator AQ HPSA 14.48
V 82.9 99212 Health 21.74 TJ Peds 23.41
Educator AQ HPSA 26.09
2) Health Educator Visit with Same Day Visit
With Supervising Physician
In some clinic settings, dues to staffing realities, it may not be possible to separate out a supervising and non-supervising physician.This scenario is the most complex in terms of billing because the MA program will not recognize an evaluation and management (E & M) billing for the services of both the health educator and the supervising physician on the same day. Under this scenario, this process might be used:
a) health educator provides screening before patient sees physician or other provider
b) health educator makes findings based on screening and documents same for review by physician and inclusion in his/her visit with the patient
c) if no “finding” that needs attention is noted, screening by the health educator cannot be billed or considered in the complexity determination of the physician visit
d) if a “finding”, physician may take the information into account as part of the office visit as part of the complexity determination. Note that the physician is not permitted to simply add the time spent by the health educator to the length of the physician visit but must justify any additional assessment or analysis in the description of the visit.
The documentation and coding process for a physician office visit preceded by a substance abuse screening by a health educator would look like this: (do chart form)
Diagnosis Code Procedure Code Provider Rate Rate Modifier
Allowed
Could vary
Example: Office Visit Physician Will TJ (Peds)
Physical or or PA vary AQ (HPSA)
Exam E & M depending
Visit on visit
complexity
Future: Once DHFS has acted to create distinct procedure and diagnosis codes for health educator screening services, , providers may utilize the following billing protocol for screening services provided to Mediaid patients:
Anticipated Future Coding for Health Educator Screening
Diagnosis Code Description Procedure Code Projected Plus Rate
Rate Modifier
V 82.9 Substance H0049 24.00 TJ (Peds)
Abuse Screen by AQ (HPSA)
Health Educator
V 82.9 Substance H0050 48.00 TJ (Peds)
Abuse Screen by AQ (HPSA)
Health Educator
Documentation Requirements for Medicaid Services (DW insert additional – include screening results, screen used, health educator training information)
Additional documentation requirements can be found in the Wisconsin Medicaid All-Provider Handbook (insert link)
-Private Payors – Typically, private payors have structured their payment strategies based on payment policies under the Medicare and Medicaid programs. It is anticipated that private payors will recognize claims for screening and brief intervention services once payment protocols are established within the public programs, and that processing claims for health educator screenings will look like this: (do chart form)
Diagnosis Code Procedure Code Provider Projected Plus Rate