Transcript Screening, Brief Intervention and Referral-to-Treatment

Screening, Brief Intervention
and Referral-to-Treatment
SBIRT Billing – Getting Started
Presented by: Penny Osmon, BA, CHC, CPC, CPC-I, PCS
Coding & Reimbursement Educator
Wisconsin Medical Society
[email protected]
Objectives
• Participants will be familiar with key clinical
definitions and how they apply to billing.
• Participants will gain an understanding of
the CPT, HCPCS and ICD-9 codes
associated with SBIRT services.
• Participants will learn the nuances of
different sites of service when performing
and billing for SBIRT services.
Key Clinical Definitions
• Brief Screen
– “a rapid, proactive procedure to identify
individuals who may have a condition or be at
risk for a condition before obvious
manifestations occur”
• Assessment or Full Screen
– More definitively categorize a patient’s
substance use.
– May be reimbursable!
Key Clinical Definitions
• Brief Intervention
– Interactions with patients intended to induce a
change in health-related behavior. Typically a
single session immediately following a
positive screen.
• Referral
– Patients that are likely alcohol or drug
dependent are typically “referred” to alcohol
and drug treatment experts for more definitive
treatment.
Key Clinical Definitions
• Brief Treatment
– Planned, several-session course of interaction
with patients designed to help patients with
alcohol or drug disorders quit or reduce the
negative impacts of substance use on their
lives.
• Follow-up
– Include interactions which occur after initial
intervention, treatment or referral service,
which are attended to reassess.
Clinical Definitions and Billing
• Brief screening is not a separately billable
service
– Full Screen or Brief Assessments are billable
• Intervention can include:
– Brief intervention
– Brief treatment
– Referral
– Follow-up
Introducing the Billing Codes
• New CPT billing codes released in the
2008 CPT manual from the American
Medical Association (AMA)
– 99408
• Alcohol and/or substance use structured screening
(eg, AUDIT, DAST), and brief intervention services;
15-30 minutes
– 99409
• Greater than 30 minutes
– Diagnosis will be dependent on payer (V82.9)
Explanation from the AMA
“A screening & brief intervention (SBI)
describes a different type of patientphysician interaction. It requires a
significant amount of time and additional
acquired skills to deliver beyond that
required for provision of general advice.
SBI techniques are discrete, clearly
distinguishable clinical procedures that are
effective in identifying problematic alcohol
or substance use.”
AMA CPT Symposium, November 2007
Explanation from the AMA
• Recognizes the importance of screening
and intervening for the person who is not
necessarily an identified substance abuser
(e.g. in the ED for a trauma)
• The screening uses structured validated
assessments, although there is no
maintained list
• The screening and intervention must be a
minimum of 15 minutes in duration
AMA CPT Symposium, November 2007
Explanation from the AMA
• Components include:
– Use of a standardized screening questionnaire.
– Feedback concerning screening results.
– Discussion of negative consequences that have
occurred; and the overall severity of the
problem.
– Motivating the patient toward behavioral change.
– Joint decision-making process regarding alcohol
and/or drug use.
– Plans for follow up are discussed and agree to.
AMA CPT Symposium, November 2007
Medicare’s Equivalent
• Medicare codes for SBI
– G0396
• Alcohol and/or substance abuse (other than
tobacco) abuse structured assessment (e.g.
AUDIT, DAST) and brief intervention, 15 to 30
minutes
– G0397
• Greater than 30 minutes
Why are the Medicare Codes
Different?
• CPT codes suggest the potential to include
“screening services”.
• Medicare does not typically cover screening
services in the absence of signs/symptoms or
illness/injury.
– Would not meet the statutory requirements for
coverage of a screening service outlined in
§1862(a)(1)(A) of the Social Security Act.
Source: CMS Transmittal 1423
Why are the Medicare
Codes Different?
• Medicare caveat
– “when performed in the context of the
diagnosis or treatment of illness or injury.”
– Medicare will make payment to physicians
only when appropriate and reasonably
necessary (i.e., when the service is provided
to evaluate patients with signs/symptoms of
illness or injury)
• Diagnosis should not be a screening diagnosis
Source: CMS Transmittal 1423
Time-Based Codes
• Both the CPT & Medicare codes are timebased
– Carefully document the time spent in
counseling and interviewing to support the
code billed
– If billing an office visit (Evaluation and
Management) E&M service, the SBI must be
separate and identifiable.
Documentation for Coding
Based on Time
“In the case where counseling and/or coordination of care
dominates (more than 50%) of the physician/patient
and/or family encounter (face-to-face time in the office or
other or outpatient setting, floor/unit time in the hospital or
nursing facility), time is considered the
key or controlling factor to qualify for a particular level of
E/M services.”
DG: If the physician elects to report the level of service
based on counseling and/or coordination of care, the total
length of time of the encounter (face-to-face or floor time,
as appropriate) should be documented and the
record should describe the counseling and/or activities to
coordinate care
Source: CMS 1997 E&M Documentation Guidelines
What About Medicaid?
• Wisconsin ForwardHealth is currently
allowing billing for women with verified
pregnancies
– H0002
• Alcohol or drug screening
– Once per patient per pregnancy
• Diagnosis code V28.9
– H0004
• Alcohol or drug intervention, per 15 minutes
– Limited to 4 hours per patient, per pregnancy
» Up to 16 units of service total
• Diagnosis code V65.4
What About Medicaid?
• H0004 continued
– The counseling and intervention services must
be provided on the same DOS or on a later
DOS than the screening.
– No Prior Authorization (PA) is required for
H0002 or H0004
– HF modifier – substance abuse screening
• Required
• Medicaid Coverage Expanding in 2010
– STAY TUNED!!!
Medicaid Documentation
• Providers are required to retain documentation that
the member receiving these services was pregnant
on the DOS.
• Providers are also required to keep a copy of the
completed screening tool(s) in the member's file.
• If an individual other than a certified or licensed
health care professional provides services, the
provider is required to retain documents concerning
that individual's education, training, and supervision.
Source: www.forwardhealth.wi.gov
on-line handbook, 2009
Summary for Wisconsin
Payer
Code
Commercial Payers
(includes
health educators)
Medicare
CPT 99408
CPT 99409
G0396
G0397
Medicaid
H0002
H0004
What about Health Educators?
• Health educators are considered
ancillary/auxiliary providers
– Not credentialed with private or federal payers
– Typically able to operate under supervision of a
credentialed provider (MD, DO, PA, NP)
• Direct Supervision
• Adhere to plan of care
• Co-signature requirement on documentation
– Codes reported will depend on payer
The Setting Matters
• Site of service for SBIRT may include:
– Ambulatory outpatient
• Office, hospital outpatient
– Place of service 11, 22
– Emergency department
• Place of service 23
– Hospital Inpatient
• Place of service 21
– FQHC/Public Health Clinic
• Place of service 50/71
SBIRT In the Office
• Free standing office
– Place of Service 11
• Provided by the health educator
– Know your payers and contracts:
• Commercial 99408 & 99409
– Under supervision
• Medicare (Incident to)
– Established E&M service (CPT 99211)
• Medicaid (Ancillary Service)
– CPT 99211 or 99212
» (documentation requirements or time)
SBIRT in a Provider Based Clinic
or Outpatient Hospital
• Place of service 22
• Billing codes depend on payer and provider of
service
• Depends on who employs the health educator
or physician
SBIRT in a Provider Based Clinic
or Outpatient Hospital
• May be applicable facility code (technical)
billed to in addition to professional code when
provider based
– Can’t bill “incident-to”, supervision requirements
are different
– Revenue Code 942 on UB-04 and SBIRT Code
Medicare Supervision Requirements
Supervision: The policy for general supervision in the
outpatient hospital setting is different from the direct
supervision requirements for the office/clinic setting.
Supervision requirements for outpatient hospital settings are
the same as the definition at 42CFR 410.27 for services at
provider based facilities. The physician/NPP supervision
requirement in the outpatient hospital setting is generally
assumed to be met where the services are performed on
hospital premises. However, to assure the assumption is
appropriate, there must be a physician/NPP, who is a member
of the hospital staff, on the hospital premises at the time of the
service and immediately available to render assistance and
direction throughout the performance of the procedure.
Documentation must indicate that this requirement is met.
Source: Medicare Benefit Policy Manual (MBPM) Chapter 15 section 60
“Immediately Available” Defined
"Immediately available" in the outpatient hospital setting
may be interpreted as equivalent to the availability of a
physician/NPP designated to manage arrests in the
hospital. The supervisor need not be in the same
department as the ordering physician/NPP or in the same
department in which the services are furnished. The
supervisor may be identified in the medical record or
hospital policy by job description, rather than by name.
For example, there may be a hospital medical officer, or
the physician/NPP responsible for the cardiac arrest
team. As long as the supervisor will be in the hospital,
immediately available if needed, and can be identified by
the hospital for purposes of Medicare claim review.
Source: Social Security Act (SSA) Section 1861(s)(2)(K)(i)
Who Employs the Billing Provider
Makes a Difference
• Could be:
– Independent billing physician
– Hospital employee
– Employee under contract
• CPT codes for E&M services will be
established or new office/outpatient codes
– 99201-99205 (new)
– 99211-99215 (established)
• Health educators are limited by payer
SBIRT in the Emergency
Department
• Place of service 23
• Will be a facility charge as well
– If SBIRT service is provided by salaried
employee of the hospital, it is included in the
facility charge and no professional service is
billed
• Billing codes depend on payer and
provider of service
SBIRT in the Inpatient Setting
• Place of service 21
• Billing codes depend on payer and
provider of service
• Could include patients in med/surg, ICU,
psych, or other inpatient area.
SBIRT in the FQHC
• Place of Service 50
• Same coding guidelines as freestanding
clinic
– Reimbursement is different
In Summary
•
Develop policy and procedure for SBIRT
services considering:
– Which patients receive SBIRT?
– When are patients referred to health
educators?
– Documentation and protocol for supervising
provider
Smoking and
Tobacco Cessation
CPT Codes
• 99406: Smoking and tobacco use
cessation counseling visit; intermediate,
greater than 3 minutes up to 10 minutes
• 99407: intensive, greater than 10 minutes
Rules in General
• Face to face
• Time and counseling must be documented
– And subtracted from E&M time
• Can be used multiple times
Example: If the E&M visit took 25 minutes and
the smoking cessation was provided face to
face for 15 minutes, the E&M if based on time,
would be 10 minutes. (99212)
– Modifier 25 appended to the E&M
Smoking Cessation
~Commercial Payer~
• Provided by health educator
– Ancillary service under on-site supervision
– E&M on same day by physician
• Documentation must indicate ancillary service by
who, and include the counseling elements and time
Smoking Cessation
~Medicare~
• CPT 99406 & 99407
– Same CPT definitions
– Deductible and co-insurance apply
– Can bill E&M on the same day with modifier 25
– Limited to 8 smoking cessation attempts in a
12 month period
Diagnosis Requirement
• Diagnosis code must reflect the condition
that is adversely affected by tobacco use,
or
• The condition the patient is being treated
for with a therapeutic agent whose
metabolism or dosing is affected by
tobacco use
Medicare Definitions
• Cessation counseling attempt: occurs
when a qualified practitioner determines
that a beneficiary meets the eligibility
requirements and initiates treatment with a
cessation counseling attempt.
• 1 Counseling attempt = up to 4 sessions
– 2 allowed per 12 months
Medicare Definitions
• Cessation counseling session: Face to
face patient contact of either the
intermediate (3-10 minutes) or the
intensive (greater than 10 minutes) type
performed either by or “incident to” the
services of a qualified practitioner for the
purposes of counseling the beneficiary to
quit smoking or tobacco use
Reimbursement
• Commercial Average
– 99406: $13
– 99407: $30
• Medicare:
– 99406 Non-facility $12.46 Facility $ 11.13
– 99407 Non-facility $24.16 Facility $23.16
• Medicaid
– Provided as E/M as ancillary service
• 99211 or 99212
What’s Next?
• SBIRT – Getting Paid
– Background, code and site of service
introduction complete, tomorrow we talk about
reimbursement
– Questions/Comments/Scenarios?
[email protected]
608-442-3781