Eric Goplerud, Ph.D. The George Washington University Medical Center Screening, Brief Intervention, Treatment and Recover Support: Getting Paid

2 Why won’t health care providers conduct routine screenings, brief counseling and treatment for substance use problems?

Ensuring Solutions to Alcohol Problems 3 Obstacles to SBIRT No time. What’s the point? Don’t know how. Can’t afford it.

Ensuring Solutions to Alcohol Problems 4

5 What Does SBIRT Cost? It depends on how you do it.  Screening Bioassay Online Paper and pencil as HRA or in a health-related location or event Automated telephone service PDA linked to electronic medical record Pop-up on electronic medical record Interview

Ensuring Solutions to Alcohol Problems 6 What Does SBIrt Cost? It depends on how you do it.  Brief Intervention and Brief Treatment Length of time Type of provider Setting Follow-up method  Specialty treatment

Ensuring Solutions to Alcohol Problems 7 SBIRT Cost Estimate Screening Low cost = $2.50 per screen  No lab, 5 minute screening by health educator High cost = $38.00 per screen  Lab plus 10 minute screening by mid-level professional

Ensuring Solutions to Alcohol Problems 8 SBI Cost Estimate Brief Intervention Low cost = $10.00 per intervention  10 minute intervention by health educator plus follow-up call High cost = $ per intervention  30 minute intervention by mid-level professional plus follow-up visit or call

Ensuring Solutions to Alcohol Problems 9 Conditions Affecting Hit Rate Screening factors  Setting & patient population  Instrument used and threshold for positive results Brief Intervention & Treatment Factors  Setting & patient population  Type of model  Whether routine, targeted or opportunistic

Ensuring Solutions to Alcohol Problems10 Likelihood of Positive Screen, BI and Treatment

5% Harmful Use 21% (26.25 million) At Risk Exceed daily limits. 70% (87.5 million) No Problem Never exceed daily limits. Willenbring, 2007 Spectrum of Alcohol Problems 5% (6.25 million) Harmful Use Exceed daily limits. Related problems. 3% (3.75 million) Dependence Daily or near-daily heavy drinking. Related problems. Withdrawal 1% (1.25 million) Chronic Dependence Almost-daily drinking. Related problems. Withdrawal Chronic or relapsing.

High Risk and Hazardous Alcohol Use Targeting the 21% who drink in ways that place themselves at risk for health problems and injury Center for Integrated Behavioral Health Policy

Ensuring Solutions to Alcohol Problems 13 Getting Paid for SBIRT HCPCS  New codes approved by CMS H0049 Screening H0050 Brief Intervention  In effect as of January 1, 2007  No state Medicaid agencies currently pay on these codes Close in some states – AZ, AK, WA

Ensuring Solutions to Alcohol Problems 14 What did we learn? Without CMS leadership

Ensuring Solutions to Alcohol Problems 15 Getting Paid for SBIRT: The Big Deal

Ensuring Solutions to Alcohol Problems 16 New codes approved by AMA Active since January  Alcohol and/or substance use structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes  greater than 30 minutes Diagnosis will be dependent on payer (V82.9) CPT – Common Procedure Terminology

Ensuring Solutions to Alcohol Problems 17 Payment CMS Schedule  Published in November 2008  RUC recommended values ~$ ~$48 Can be billed as a separate or added service CPT codes adopted by most health plans (86% commercial insurers) and 17 State Medicaid Aetna, CIGNA, Anthem Blue Cross and Blue Shield, HealthPlus, HealthPartners, Office of Personnel Management (Federal Employees)

18 Reimburses, or will reimburse on SBI Codes 99408/99409 Aetna California PPO 310 Anthem California National PPO 152 BC of California HMO 0 Health Net of California HMO 0 Health Net of California PPO 26 Kaiser Northern California HMO 58,739 Kaiser Southern California HMO 48,000 UnitedHealthcare of California PPO 5

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

What gets paid, gets done Office/outpatient visit, new, 30 minutes Emergency dept visit, moderate complexity Physician or healthcare prof. follow-up phone call min (Not Medicare reimb.) Administration, interpretation of health risk assessment instrument (not Medicare reimb.) Preventive medicine, individual, 30 min (not Medicare reimb.) Removal of spleen, total Removal of brain abscess SBI 30 minutes or more 1.67 RVUs

2008 RVUs for SBI and comparable clinical procedures RVUs 90804Psychotherapy, office, min Psychotherapy, hospital, min Office/outpatient visit, new 20 min SBI 15 to 30 min Office/outpatient visit, new 30 min Prevention visit, new, age SBI over 30 min1.67

Reimbursement for SBI PayerCodeDescriptionFee Schedule Commercial Insurance and Medicaid CPT Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51 Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

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

“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)

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

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

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.

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

Smoking and Tobacco Cessation

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

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

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

Smoking Cessation ~Medicare~ CPT & –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

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

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

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

Reimbursement Commercial Average –99406: $13 –99407: $30 Medicare: –99406 Non-facility $12.46 Facility $ –99407 Non-facility $24.16 Facility $23.16 Medicaid –Provided as E/M as ancillary service or 99212

Billing with Evaluation and Management (E&M) Codes

58 SBI Reimbursement Strategies Providers can be reimbursed for SBI – even without specific codes. resources_show.htm?doc_id=385233&cat_id=964

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)

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

Ensuring Solutions to Alcohol Problems 68

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

Ensuring Solutions to Alcohol Problems 70

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

Ensuring Solutions to Alcohol Problems 73

What is Incident-to??

What is Incident-to? It is a Medicare guideline ONLY! “Incident to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness”

Five Key Concepts of “Incident-to” 1.Professional service 2.Location 3.Employment relationship 4.Incidental but physician/NPP performs initial service 5.Supervision, direct Must meet all criteria for “incident-to”

Medicare’s Personal Performance Policy General rule –Physicians (and non- physician practitioners NPP’s,) are only paid for what they personally perform and document

An Exception to Medicare’s General Rule Incident to services are performed by personnel who are NOT physicians, but are paid for performing physicians services

Who can provide Incident-to services??

Definition of “Auxiliary Personnel” Auxiliary Personnel – “any individual” who is acting under the supervision of a physician…..

Auxiliary Personnel “Any individual” – CMS deliberately chose this term when defining “auxiliary personnel” –“So that the physician (or other practitioner), under his or her discretion and license, may use the service of anyone ranging from another physician to a medical assistant.” –“...impossible to exhaustively list all incident-to services and those specific auxiliary personnel who may perform each service.” Federal Register/Vol. 66, No. 212/ Thursday November 1, 2001, pgs – 55268

Auxiliary Personnel vs. Practitioners Auxiliary Staff –Such as RNs, technicians, health educators and other aids (not a complete list) –May meet criteria for Practitioners/NPP –PA, NP, certified nurse midwife, clinical psychologists, clinical social workers, certified registered nurse anesthetists and clinical nurse specialists –Not restricted to level of E/M service or appropriate specialty code (must be within scope of practice)

***Cautionary Note*** Each occasion of service by auxiliary staff does not necessarily warrant the billing of a personal, professional service by the physician.

Where can you apply Incident-to?

2. Location, Location, Location Physician’s office or clinic ONLY Applies to outpatient clinic setting but not outpatient hospital clinic setting No incident-to billing in an “ institutional setting, ” such as a hospital or a Skilled Nursing Facility (SNF)

Office within an Institution Must be confined to a separately identified part of the facility used solely as the physician’s office and –Cannot be construed to extend throughout the entire institution Services performed outside the “office” area –Subject to the coverage rules outside the office setting

3. Employment Requirements May be a part-time, full-time or leased employee or independent contractor –Both the supervising physician and the auxiliary personnel furnishing the service must meet the employment requirements –Reassignment of benefits must be executed

4. Initial Service Requirement To bill incident-to, ‘there must have been a direct, personal, professional service furnished by a the physician to initiate the course of treatment of which the service being performed by the non-physician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects his/her continuing active participation in and management of the course of treatment.’

Established Patient “An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.” (CPT, 2009)

Established Plan of Care The personnel performing the incident-to service should: –Document the ‘link’ between their face-to-face service and the preceding physician service to which their service in incidental. –Reference by date and location the precedent providers’ service that supports the active involvement of the physician. –Legible record both their identity and credentials

5. Direct Supervision “Direct supervision in the office setting does not mean that the physician must be present in the same room with his/her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing the services.”

Direct Supervision – What it is Physician readily available in the office suite seeing patients in an adjacent exam room. There must be a specific physician responsible for the supervision of the billed service.

Direct Supervision – What it is not Physician doing rounds at the hospital and the auxiliary staff performing the service in the office. Physician having lunch downtown and is available by phone.

Supervising Physician The physician who performed the initial assessment and initiated the course of treatment does not need to be the physician supervising the incident-to service.

CPT code & How to Bill Incident-to (Medicare guideline)

CPT code “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.” (CPT, 2009)

Criteria for billing as “incident-to” Must be an established patient There must be an established plan of care. There must be an E/M service provided by an employee of the physician. Must be provided in the office. There must be direct physician supervision.

Auxiliary Personnel Can only bill lowest level of E/M service, code Medicare will pay the claim at 100% of the physician fee schedule, even though the services were furnished by the auxiliary personnel. (health educator)

Non-Physician Personnel (NPP) Nurse Practitioner Nurse Midwife Clinical Nurse Specialist Physician Assistant Clinical Psychologist Clinical Social Workers Physical/Occupational Therapists

Non-Physician Personnel NPP can bill E/M levels Medicare will pay the claim at 100% of the physician fee schedule, even though the services were furnished by the NPP. NPP’s can also establish the plan of care. –Health educators could bill “incident to” a initial service provided by a NPP.

Performance of E/M Service No specific criteria in CPT for a (eg. level of history, exam or medical decision making). Face-to-face encounter with the auxiliary personnel and the patient consisting of both ‘evaluation and management’.

Documentation The medical record must be adequately documented to reflect the reason for the patient’s visit and any treatment rendered. The medical record must include elements of history obtained, examination performed and/or clinical decision making. The medical record must support physician supervision.

Summary Check for established patient and plan of care. Watch the location. Health educator must be employed by billing physician or NPP. Heed the supervision rules. Document, document, document.

104 SBI Reimbursement Strategies Providers can be reimbursed for SBI – even without specific codes. resources_show.htm?doc_id=385233&cat_id=964

Facilitated self change Heavy drinking only Chronic Disease Management Brief motivational counseling Medical management + pharmacotx or CBI Specialized remission- oriented treatment Increased quantity, frequency & consequencesof alcohol use Harmful drinking Dependence Extended Continuum

The extended continuum Facilitated self change Moderate Severe Chronic Disease Management Brief motivational counseling Medical management + pharmacotx or CBI Specialized remission- oriented treatment Widespread availability Internet Toll-free telephones (QUIT lines) EAP & occupational health Schools & workplaces Primary care, hospital emergency departments Criminal justice system

The extended continuum Facilitated self change Moderate Severe Chronic Disease Management Brief motivational counseling Medical management + pharmacotx or CBI Specialized remission- oriented treatment Next step Primary care General MH care Bulk of people needing treatment are here

The extended continuum Facilitated self change Moderate Severe Chronic Disease Management Brief motivational counseling Medical management + pharmacotx or CBI Specialized remission- oriented treatment SUD Specialty sector Fully integrated with medical and psychiatric care systems Able to manage severe co-morbidities Disease management for chronic or relapsing disorders

Eric Goplerud, Ph.D. Director 2021 K St. NW, Suite 800 Washington, DC integratedbehavioralhealth.org Center for Integrated Behavioral Health Policy Department of Health Policy, The George Washington University Medical Center