1. 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

2. 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.

3. 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!

4. 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.

5. 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.

6. 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

7. 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; minutes
99409
Greater than 30 minutes
Diagnosis will be dependent on payer (V82.9)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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!!!

18. 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:
on-line handbook, 2009
The appendix B in the current coding and billing manual achieves this documentation.

19. Summary for Wisconsin Payer Code Commercial Payers (includes
health educators)
CPT 99408
CPT 99409
Medicare
G0396
G0397
Medicaid
H0002
H0004

20. 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

21. 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

22. SBIRT In the Office Free standing office
Place of Service 11
Provided by the health educator
Know your payers and contracts:
Commercial & 99409
Under supervision
Medicare (Incident to)
Established E&M service (CPT 99211)
Medicaid (Ancillary Service)
CPT or 99212
(documentation requirements or time)

23. 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

24. 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

25. 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 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

26. “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)

27. 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
(new)
(established)
Health educators are limited by payer

28. 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

29. 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.

30. SBIRT in the FQHC Place of Service 50
Same coding guidelines as freestanding clinic
Reimbursement is different

31. 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

32. Smoking and Tobacco Cessation

33. 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

34. 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.

35. 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

36. Smoking Cessation ~Medicare~
CPT & 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)

37. 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

38. 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

39. 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

40. Reimbursement Commercial Average Medicare: Medicaid 99406: $13
99407: $30
Medicare:
99406 Non-facility $ Facility $ 11.13
99407 Non-facility $ Facility $23.16
Medicaid
Provided as E/M as ancillary service
99211 or 99212

41. What’s Next? SBIRT – Getting Paid
Background, code and site of service introduction complete, tomorrow we talk about reimbursement
Questions/Comments/Scenarios?