Screening, Brief Intervention and Referral-to-Treatment SBIRT Billing – Getting Started

1
Screening, Brief Intervention and
Referral-to-TreatmentSBIRT Billing Getting
Started

• Presented by Penny Osmon, BA, CHC, CPC, CPC-I,
  PCS
• Coding Reimbursement Educator
• Wisconsin Medical Society
• Penny.osmon_at_wismed.org

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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.

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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 patients
  substance use.
• May be reimbursable!

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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.

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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.

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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

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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)

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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
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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

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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 agreed to.
• AMA CPT Symposium, November 2007

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Medicares Equivalent

• Medicare codes for SBI
• G0396
• Alcohol and/or substance abuse (other than
  tobacco) structured assessment (e.g. AUDIT, DAST)
  and brief intervention, 15 to 30 minutes
• G0397
• Greater than 30 minutes

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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

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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

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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) EM service, the SBI must be separate
  and identifiable.

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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 EM Documentation Guidelines
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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

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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!!!

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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

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Summary for Wisconsin
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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

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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

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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 EM service (CPT 99211)
• Medicaid (Ancillary Service)
• CPT 99211 or 99212
• (documentation requirements or time)

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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

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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
• Cant bill incident-to, supervision
  requirements are different
• Revenue Code 942 on UB-04 and SBIRT Code

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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
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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)
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Change for 2010

• OPPS 2010 Final Rule
• Allows therapeutic services to be provided under
  direct supervision of MD, DO, PA, NP, CSW and
  more
• Greater flexibility in location of the
  supervising provider
• Further defines immediately available to mean
  able to intervene immediately
• For 2009, still require supervising provider in
  the actual department

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Who Employs the Billing Provider Makes a
Difference

• Could be
• Independent billing physician
• Hospital employee
• Employee under contract
• CPT codes for EM services will be established or
  new office/outpatient codes
• 99201-99205 (new)
• 99211-99215 (established)
• Health educators are limited by payer

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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

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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.

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SBIRT in the FQHC

• Place of Service 50
• Can also be 11
• Same coding guidelines as freestanding clinic
• Reimbursement is different

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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

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Smoking and Tobacco Cessation
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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

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Rules in General

• Face to face
• Time and counseling must be documented
• And subtracted from EM time
• Can be used multiple times
• Example If the EM visit took 25 minutes and
  the smoking cessation was provided face to face
  for 15 minutes, the EM if based on time, would
  be 10 minutes. (99212)
• Modifier 25 appended to the EM

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Smoking Cessation Commercial Payer

• Provided by health educator
• Ancillary service under on-site supervision
• EM on same day by physician
• Documentation must indicate ancillary service by
  who, and include the counseling elements and time

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Smoking CessationMedicare

• CPT 99406 99407
• Same CPT definitions
• Deductible and co-insurance apply
• Can bill EM on the same day with modifier 25
• Limited to 8 smoking cessation sessions in a 12
  month period

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Medicare 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

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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 attempts allowed per 12 months

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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

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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

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Whats Next?

• SBIRT Getting Paid
• Background, code and site of service introduction
  complete, tomorrow we talk about reimbursement
• Questions/Comments/Scenarios?
• Penny.osmon_at_wismed.org
• 608-442-3781