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 Penny.osmon@wismed.org

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 patient-physician 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 time-based 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 The appendix B in the current coding and billing manual achieves this documentation.

Summary for Wisconsin Payer Code Commercial Payers (includes health educators) CPT 99408 CPT 99409 Medicare 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 Less than 3 minutes is bundled into the E/M – E&M must be signifance and differnet to be billed in addition.

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 Claims for Smoking and Tobacco-Use Cessation Counseling Services should be submitted on Form CMS-1450 or its electronic equivalent. The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 73X, 74X, 75X, 83X, and 85X. Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for Smoking and Tobacco-Use Cessation Counseling services Provider Type Revenue Code Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) 052X Indian Health Services (IHS) 0510 Critical Access Hospitals (CAHs) Method II 096X, 097X, 098X All Other Providers 0942 Payment for outpatient services is as follows: Type of Facility Method of Payment Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) All-inclusive rate (AIR) for the encounter Indian Health Service (IHS)/Tribally owned or operated hospitals and hospital- based facilities All-inclusive rate (AIR) IHS/Tribally owned or operated non-hospital-based facilities Medicare Physician Fee Schedule (MPFS) IHS/Tribally owned or operated Critical Access Hospitals (CAHs) Facility Specific Visit Rate Hospitals subject to the Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) Hospitals not subject to OPPS Payment is made under current methodologies Skilled Nursing Facilities (SNFs) NOTE: Included in Part A PPS for skilled patients. Medicare Physician Fee Schedule (MPFS) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Medicare Physician Fee Schedule (MPFS) Home Health Agencies (HHAs) Medicare Physician Fee Schedule (MPFS)

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 Medicare: Medicaid 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? Penny.osmon@wismed.org 608-442-3781