1 Screening, Brief Intervention and Referral-to-Treatment SBIRT Billing – Getting Started Presented by: Penny Osmon, BA, CHC, CPC, CPC-I, PCSCoding & Reimbursement EducatorWisconsin Medical Society
2 ObjectivesParticipants 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 ScreenMore definitively categorize a patient’s substance use.May be reimbursable!
4 Key Clinical Definitions Brief InterventionInteractions with patients intended to induce a change in health-related behavior. Typically a single session immediately following a positive screen.ReferralPatients 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 TreatmentPlanned, 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-upInclude 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 serviceFull Screen or Brief Assessments are billableIntervention can include:Brief interventionBrief treatmentReferralFollow-up
7 Introducing the Billing Codes New CPT billing codes released in the 2008 CPT manual from the American Medical Association (AMA)99408Alcohol and/or substance use structured screening (eg, AUDIT, DAST), and brief intervention services; minutes99409Greater than 30 minutesDiagnosis 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 listThe screening and intervention must be a minimum of 15 minutes in durationAMA 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 SBIG0396Alcohol and/or substance abuse (other than tobacco) abuse structured assessment (e.g. AUDIT, DAST) and brief intervention, 15 to 30 minutesG0397Greater 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 diagnosisSource: 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 billedIf 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 thekey 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 therecord should describe the counseling and/or activities to coordinate careSource: CMS 1997 E&M Documentation Guidelines
16 What About Medicaid?Wisconsin ForwardHealth is currently allowing billing for women with verified pregnanciesH0002Alcohol or drug screeningOnce per patient per pregnancyDiagnosis code V28.9H0004Alcohol or drug intervention, per 15 minutesLimited to 4 hours per patient, per pregnancyUp to 16 units of service totalDiagnosis 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 H0004HF modifier – substance abuse screeningRequiredMedicaid Coverage Expanding in 2010STAY 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, 2009The appendix B in the current coding and billing manual achieves this documentation.
19 Summary for Wisconsin Payer Code Commercial Payers (includes health educators)CPT 99408CPT 99409MedicareG0396G0397MedicaidH0002H0004
20 What about Health Educators? Health educators are considered ancillary/auxiliary providersNot credentialed with private or federal payersTypically able to operate under supervision of a credentialed provider (MD, DO, PA, NP)Direct SupervisionAdhere to plan of careCo-signature requirement on documentationCodes reported will depend on payer
21 The Setting Matters Site of service for SBIRT may include: Ambulatory outpatientOffice, hospital outpatientPlace of service 11, 22Emergency departmentPlace of service 23Hospital InpatientPlace of service 21FQHC/Public Health ClinicPlace of service 50/71
22 SBIRT In the Office Free standing office Place of Service 11Provided by the health educatorKnow your payers and contracts:Commercial & 99409Under supervisionMedicare (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 22Billing codes depend on payer and provider of serviceDepends 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 basedCan’t bill “incident-to”, supervision requirements are differentRevenue 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 physicianHospital employeeEmployee under contractCPT 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 23Will be a facility charge as wellIf SBIRT service is provided by salaried employee of the hospital, it is included in the facility charge and no professional service is billedBilling codes depend on payer and provider of service
29 SBIRT in the Inpatient Setting Place of service 21Billing codes depend on payer and provider of serviceCould 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 clinicReimbursement is different
31 In SummaryDevelop policy and procedure for SBIRT services considering:Which patients receive SBIRT?When are patients referred to health educators?Documentation and protocol for supervising provider
33 CPT Codes99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes99407: intensive, greater than 10 minutes
34 Rules in General Face to face Time and counseling must be documented And subtracted from E&M timeCan be used multiple timesExample: 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&MLess 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 educatorAncillary service under on-site supervisionE&M on same day by physicianDocumentation must indicate ancillary service by who, and include the counseling elements and time
36 Smoking Cessation ~Medicare~ CPT & 99407Same CPT definitionsDeductible and co-insurance applyCan bill E&M on the same day with modifier 25Limited to 8 smoking cessation attempts in a 12 month periodClaims 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 servicesProvider Type Revenue CodeRural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) 052XIndian Health Services (IHS) 0510Critical Access Hospitals (CAHs) Method II 096X, 097X, 098XAll Other Providers 0942Payment for outpatient services is as follows:Type of Facility Method of PaymentRural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) All-inclusive rate (AIR) for the encounterIndian 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 RateHospitals subject to the Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC)Hospitals not subject to OPPS Payment is made under current methodologiesSkilled 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, orThe condition the patient is being treated for with a therapeutic agent whose metabolism or dosing is affected by tobacco use
38 Medicare DefinitionsCessation 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 sessions2 allowed per 12 months
39 Medicare DefinitionsCessation 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: $30Medicare:99406 Non-facility $ Facility $ 11.1399407 Non-facility $ Facility $23.16MedicaidProvided as E/M as ancillary service99211 or 99212
41 What’s Next? SBIRT – Getting Paid Background, code and site of service introduction complete, tomorrow we talk about reimbursementQuestions/Comments/Scenarios?