Screening, Brief Intervention and Referral-to-Treatment SBIRT Billing – Getting Paid Presented by: Penny Osmon Coding & Reimbursement Educator Wisconsin Medical Society

Objectives Participants will learn how to bill for SBIRT services when performed with other services on the same day. Participants will have an understanding of documentation requirements for reimbursement. Participants will learn when to append modifiers. Participants will gain knowledge of various reimbursement models for federal and commercial payers.

Reimbursement for SBIRT Resource Based Relative Value Scale (RBRVS) –Relative Value Units (RVU) Used by Medicare and HMO’s to establish rates Medicaid has fee schedule amounts based on rendering provider

Reimbursement for SBIRT SBIRTWork RVUTotal Facility RVU Total Non- Facility RVU & G & G

Reimbursement for SBIRT Medicare –G0396 Facility $30.23 Non-Facility $28.91 –G0397 Facility $57.63 Non-Facility $58.96 –99211 Facility $8.27 Non-Facility $ % if reported by PA/NP Medicaid –H0002 (pregnant) $35.35 –H0004 (pregnant) $20.23 –99212 (non-pregnant) No modifier $21.96 HPSA modifier –Under 18 $28.37 –Over 18 $26.35 TJ modifier –$23.65

Reimbursement for SBIRT Commercial Payers –99408: averages $33.41 –99409: averages $65.51 –Diagnosis code for best practice: V82.9, Screening for unspecified condition

Some Medicaid “Need to Knows”

Health Professional Shortage Area (HPSA) Enhanced reimbursement –Primary Care and ED Based on address of: –Either the billing provider, or –The enrolled member’s address Incentive is an additional 20% of the maximum fee amount –Requires modifier AQ

TJ Modifier Medicaid only Enhances payment for pediatric services Applied to CPT – –Patient under age 18 –Applies specifically for SBIRT when or is billed for services by a health educator

Documentation Requirements Name of the patient Who provided the service The purpose/need for the service –(medical necessity or reason) Accurate description of the service –Legible if hand written Date of service and place of service Quantity and level of service

Health Educator is the Provider Medicaid –Billing under E/M codes as ancillary provider type using CPT or Medicare –Bill “Incident-to” using CPT Commercial Payers –SBIRT codes “under supervision” Is it mental health benefit or medical benefit?

Ancillary Provider Guidelines Medicaid rules include: –Direct, immediate, on-site supervision of a physician –Services are pursuant to the plan of care –The supervising physician has not also provided Medicaid reimbursable service during the same office or outpatient E&M Can’t bill in addition to or combine the services Health educators meet the definition of ancillary provider

Ancillary Provider Guidelines Claims are submitted to Medicaid using the supervising physician’s NPI –Using the lowest appropriate level office visit CPT code for the services performed, typically a or –Supervising physician is rendering provider

99211 and : “Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.” Source: CPT Professional Edition,2009

99211 and : “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history A problem focused exam Straightforward medical decision making Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face to face with the patient and/or family. Source: CPT Professional Edition,2009

Billing with Evaluation and Management (E&M) Codes

Evaluation & Management (E&M) Elements History, Exam and Medical Decision Making –Need 3 of 3 for new patients (99201 – 99205) –Need 2 of 3 for established patients ( )

Evaluation & Management (E&M) Elements Or may report based on time –Greater than 50% of visit must be counseling and/or coordination of care Documentation is key! –Both time and “what” the counseling entailed –Example: I spent 15 minutes with the patient today and all 15 minutes were used counseling the patient on potential risk behaviors. »The note should include the nature of the counseling

Billing with E/M Codes Physicians are typically defined by specialty and group –All physicians within the same specialty, same group = 1 physician for billing purposes Example: Two primary care physicians provide two E&M services on the same day to the same patient, only one E&M can be billed, combining documentation

Multiple Services on the Same Day Physicians can bill for an E&M and the provision of SBIRT services on the same day when personally performing the services –Example: (E&M, established patient) & (SBIRT for commercial payer) –Example: (E&M, new patient) & G0396 (SBIRT for Medicare)

Example 50-year-old male seen for unscheduled visit for cold symptoms and wheezing. History of acid reflux, headaches, mild hypertension, alcoholism in three first-degree relatives. The patient recently lost his job, and uses alcohol socially several time per week. DX: URI, prescribed an inhaled beta-2 agonist. The physician assessed risk of alcohol use disorder with a standard 10-item AUDIT questionnaire. Patient provided feedback about drinking and medical concern, generated option to reduce drinking, developed plan and commitment to change. Greater than 30 minutes of SBI. E&M and may be billed

Example Patient presents for an annual preventive exam. During the exam, physician performs a CAGE survey to assess alcohol abuse as protocol. Patient is referred to an alcohol program. Twenty minutes is spent convincing the patient there is a drinking problem. The service described does not sound like specific SBI interventions, but may be reported with an E&M. AMA CPT Symposium, November 2007

Multiple Services on the Same Day If a physician and a health educator provide multiple services to the same patient on the same day, only the physician (credentialed provider) may bill for services. –E&M would be billed based on the 3 elements or on time and counseling/coordination of care –Only historical elements from the health educator could be included in the level of service Past family, social, medical history, and Review of systems (For Medicare)

Historical Information For purposes of SBIRT may include: –Historical information gathered during alcohol and drug screening and assessment

Site of Service Matters

SBIRT in the ED CPT codes are: – –SBIRT Can be billed in addition when performed by a credentialed provider 99408, 99409, G0396, G0397 Would be rare for separate payment to health educator

SBIRT in the FQHC Same billing requirements as the office –Reimbursement will be “encounter rate” and is all inclusive –Encounters with more than one health professional and multiple encounters with the same health professionals which take place on the same day and at a single location constitute a single visit, except when one of the following conditions exist: (a) after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; (b) the patient has a medical visit and a clinical psychologist or clinical social worker visit. Source: IOM , Chapter 1, Section 20.1

SBIRT in the Hospital Outpatient –Both facility and professional fee E/M codes (reported by both), and/or SBIRT codes If provided by health educator, payer and employment drives coding and reimbursement

SBIRT in the Hospital Inpatient –Facility fee = DRG No separate payment, “bundled in” –Professional fee E/M ( or ) and SBIRT codes –No separate payment for health educator

Commercial Payer Reimbursement The verdict is out –Several have been asked to consider payment when performed by a health educator STAY TUNED!

Commercial Payer Information Anthem: & are covered –Processed under medical benefit for Wisconsin insured members –No payment if billed with preventive CPT codes & Physicians Plus: & covered –Time and discussion need to be documented

Commercial Payer Information United Healthcare: & covered –Processing will determine if they fall under behavioral or medical benefit Untiy: & covered –Behavioral health benefit WEA: & covered WPS: & are pended and sent to medical management for review of medical necessity

Commercial Payer Information Cigna: & covered –The screening instrument used and the nature of the intervention activity should be documented in the medical record. The work effort for the codes is separate and distinct from all other E&M services performed in the same session. If the screening shows no intervention is required, the screening should be included in an E&M or preventive medicine service.

Example Still must check contracts Patient has E&M visit with physician. Health Educator see patients for SBI on the same day during same encounter. Both the E&M and SBIRT code are billed under the NPI of the physician Documentation MUST be clear that SBIRT was provided by ancillary staff –Employment requirement On- site supervision required

Contracting Demonstrate through data cost- effectiveness and measurable quality –How do health educators fit into the continuum of care, creates value Use information systems to identify costs, patient outcomes and satisfaction levels, improved quality and value to the payer Negotiate for credentialing health educators

Summary Medicaid changes coming in 2010 Commercial payers –Waiting for answers –Still work to do through contracting Start billing and getting reimbursed for SBIRT services

Questions/Comments/Discussion Thank You