1. Screening and Brief Intervention: The 2008 CPT Codes Blue Cross Blue Shield Association Eric Goplerud, Ph.D. December 11, 2007

2. 2 What is SBI: Ask, Inform, Motivate ASK:  On admission for new patients and at least once annually for existing patients, ask two preliminary screening questions:  When was the last time you had more than four drinks in one day?  Do you use marijuana, cocaine, or other drugs?  If “No” to both questions, simply continue with necessary medical care and use the appropriate Evaluation and Management (E&M) procedure code.  If “Yes,” conduct a more in-depth screening (AUDIT and/or DAST recommended).

3. 3 What is SBI: Inform INFORM  Use the results of screening and any other information (GGT, BAC, etc) in the patient’s medical record to conduct a brief intervention.  A qualified health care professional presents the results of the screening to the patient, comparing the patient’s substance use to healthy standards of use (NIAAA Guidelines) and providing information about the impact that current use patterns could have on the patient’s health and well-being.

4. 4 What is SBI: Motivate MOTIVATE  A qualified health care professional leads a discussion that focuses on the impact of the patient’s substance use and possible ways that the patient might change behavior. Discuss ambivalence and reasons for change. Generate plans and commit to plans to change behavior. Schedule check-up on change plan or if patient is referred to a specialist for more intensive intervention. Document screening and brief intervention is entered into the patient’s record.

5. 5 Likelihood of Positive Screen, BI and Treatment

6. 6 New Procedure Codes for SBI HCPCS  New codes approved by CMS H0049 Screening H0050 Brief Intervention  In effect as of January 1, 2007  Wisconsin Medicaid currently pays  Close in some states – NY, CA, TN, CO, RI, GA, HI

7. 7 2008 CPT & Medicare “G” Codes for SBI

8. 8 New codes published Nov 2 in 2008 CPT Manual  99408 Alcohol and/or substance use structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes  99409 greater than 30 minutes Separate or added service Major commercial health plans anticipate use in 2008 2008 CPT Common Procedure Terminology

9. 9 2008 Medicare CMS Physician Payment Schedule CMS Medicare codes and Relative Values published Nov. 7 in Federal Register  Directs Medicare FFS to use new “G” codes G0369 – Assessment and BI 15 to 30 minutes G0370 – 30 minutes plus  Relative Values 99408, G0396 ~$24 99409, G0379 ~$48

10. 10 Characteristics of Screening and Brief Intervention (SBI) CPT and CMS Physician Payment Schedule signal AMA and CMS recognition that SBI is a separate and distinct medical procedure  requires 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. SBI may be opportunistically delivered in general and specialty medical practice with patients who may not be seeking substance use care or meet DSM/ICD-9 diagnostic criteria of abuse or dependence

11. 11 Clinical Vignette (99408) A 45-year-old male is brought to the emergency department (ED) after falling down a flight of stairs and briefly losing consciousness. A comprehensive history and physical examination revealed a Colles fracture, two prior injury-related ED visits, in one of which a suspicion of alcohol involvement was documented and a history of drinking alcohol-containing beverages two to three times per week. Based upon the H&P, the physician considers the risk of an underlying alcohol problem to be significant, and elects to screen the patient. Total SBI time is 20 minutes.

12. 12 Clinical Vignette (99409) 42-year-old female at unscheduled ambulatory visit for wheezing. History of acid reflux, headaches, insomnia, mild hypertension, alcohol problems in two first-degree relatives. The patient recently left her job, and uses alcohol socially several times per week. DX: mild asthma exacerbation, prescribed an inhaled beta-2 agonist. The physician assessed risk of alcohol use disorder with a standard 10-item AUDIT questionnaire. Physician provides feedback about drinking and expresses medical concern, assists patient to explore ambivalence about changing drinking, helps her generate options to reduce unhealthy drinking, develops a plan and commitment to change. Total SBI time is 35 minutes.

13. 13 Volume Estimates by Insurance Type Private state adjuster1.00 Annual number of outpatient claimants400,000 Annual number of emergency department claimants150,000 Annual number of inpatient claimants75,000 Likely number of unhealthy drinkers in entire claimant pool (outpatient)7.50%26,880 Likely number of unhealthy drinkers in entire claimant pool (ED)13.55%18,328 Likely number of unhealthy drinkers in entire claimant pool (Inpatient)7.40%4,875

14. 14 Proportion of all claimants screened (% can be adjusted for vigorous promotion of screening)0.4 Proportion of hazardous drinkers identified in routine SBI program (outpatient)0.88,602 Proportion of hazardous drinkers identified in routine SBI program (ED)0.85,865 Proportion of hazardous drinkers identified in routine SBI program (inpatient)0.751,463 Total number of hazardous drinkers detected if screening performed all 3 settings15,930

15. 15 Cost of Brief Intervention (CPT reimbursementt) Number likely to receive intervention0.9515,134 Cost to health plan for screening & brief intervention -- 15-30 minutes CPT 99409 or G036932%$24$116,467 Cost to health plan for screening & brief intervention -- 30 + minutes CPT 99409 or G037018%$48$131,026 Total cost to health plan to reimburse for screening & brief intervention$247,493

16. 16 Derivation of Savings Due to Brief Intervention savings from reduced health care utilization (outpatient)$523$4,273,904 savings from reduced health care utilization (ED)$488$2,721,673 savings from reduced health care utilization (Inpatient)$488$678,910 Total savings due to screening & brief intervention$7,674,486 Net Savings $7,426,993 Savings per positive screen $466 Return on Investment: savings/expenditures31

17. Ensuring Solutions to Alcohol Problems GEORGE WASHINGTON UNIVERSITY MEDICAL CENTER Eric Goplerud, Ph.D., Director 2021 K Street NW, Suite 800 Washington, DC 20006 P: (202) 296-6922 F: (202) 296-0025 www.ensuringsolutions.org