Behavior Change Intervention FAQ

 

FAQ 1.  I understand there are codes to report services involving behavior modification counseling. What are the general requirements for these types of services?

Counseling Risk Factor Reduction and Behavior Change Intervention (CPT® 99406-99409) and HCPCS G0396-G0397  are face-to-face services provided by a physician or other qualified healthcare professional*. However, the Alcohol and Substance Abuse codes specify a "structured assessment" and brief intervention must be performed. Standardized evidence-based screening instruments and tools with reliable documentation and appropriate sensitivity are required in order to report any of these services (e.g., AUDIT, DAST and T-ACE for alcohol, etc.).  Behavior Change Intervention services involve specifically validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, providing specific suggested actions, and arranging for services and follow up. 

*An emergency physician cannot code/bill for behavior change services provided by other qualified healthcare professionals unless the individual is employed by the physician group. 

FAQ 2.  May I also report an ED E/M on the same date of service as these services?

You may report an E/M code on the same date you provide the behavior change intervention as long as it is distinct, separately identifiable, and effort made to provide the counseling service is not used as a basis for the E/M code selection.  Utilize modifier -25 to indicate the Evaluation/Management service was a significant separately identifiable service from the Behavior Change Intervention. 

FAQ 3.  What are the specific codes to report smoking/tobacco abuse screening and counseling services?

 

 

99406

 

Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407

    Intensive, greater than 10 minutes

 

Effective September 30, 2016, HCPCS codes G0436 and G0437 are deleted for Medicare. Use existing CPT codes 99406 and 99407 for smoking and tobacco-use cessation counseling visits.   Check with other local payers to determine whether G0436 and G0437 have been replaced with 99406 and 99407.

ICD-10 codes which support smoking prevention counseling:  Use Tobacco abuse counseling (Z71.6) with the applicable additional code: Nicotine dependence, unspecified (F17.20-), Nicotine dependence, cigarettes (F17.21-), Nicotine dependence, chewing tobacco (F17.22-), Nicotine dependence, other tobacco product (F17.29-), Tobacco use disorder [smoking] complicating pregnancy, childbirth, and the puerperium (O99.33-), Toxic effect of chewing tobacco (T65.21-A), Toxic effect of tobacco cigarettes/smoke (T65.22-A), Toxic effect of other tobacco and nicotine (T65.29-A), Tobacco use (Z72.0), and Personal history of nicotine dependence (Z87.891). [“=” is a placeholder for additional character]

Frequency: Two cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to  8 sessions per year.

Source:  https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf, p.8

FAQ 4.  What are the specific requirements and RVU for the smoking/tobacco abuse screening and counseling codes?

Document time spent counseling the patient about smoking cessation. Smoking cessation counseling codes are time based. The intermediate service requires greater than three minutes up to ten -(10) minutes.  The intensive service requires greater than 10 minutes. Document patient readiness for change and barriers to change, advising a change in behavior, and providing specific suggested actions. These codes are used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury.

CPT

Work

PE

Malpractice/PLI

Total RVU

99406

0.24

0.09

.02

0.35

99407

0.50

0.19

0.04

0.73

 

FAQ 5.  What are the specific codes to report alcohol and/or substance abuse services? 

 

 

99408

 

Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services 15 to 30 minutes. Services less than 15 minutes are not reportable with 99408.

99409

     Greater than 30 minutes

You may not report 99409 in conjunction with 99408. Codes 99408 and 99409 are used only for initial screening and brief intervention.

Medicare has established the following HCPCS G Codes for alcohol and/or other substance abuse. Note the G codes require a "structured assessment" and brief intervention

 

G0396

 

Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services 15-30 minutes.

G0397

Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and intervention greater than 31 minutes.

These codes may be reported when performed in physician's offices and outpatient hospitals. (Medicare Learning Network Matters Number: SE1013, August, 2012 Medicare Learning Network: ICN 904084 June 2014), and via Telehealth. 

ICD-10 codes which support substance abuse screening:: Alcohol related disorders (F10.-), Opioid related disorders (F11.-), Cannabis related disorders (F12.-), Sedative, hypnotic, or anxiolytic related disorders (F13.-), Cocaine related disorders (F14.-), Other stimulant [amphetamine] related disorders (F15.-), Hallucinogen [PCP, ecstasy] related disorders (F16.-), Inhalant related disorders (F18.-), Other psychoactive substance related [polysubstance] disorders (F19.-), Alcohol use complicating pregnancy, childbirth, and the puerperium (O99.31-), Drug use complicating pregnancy, childbirth, and the puerperium (O33.32-),

Note: Additional ICD-10-CM codes may apply.

Note-G0442 and G0443 are similar Medicare codes but can ONLY be used by qualified primary care physicians or other primary care practitioners in a primary care setting. (Medicare Claims Processing Manual 2014, Chapter 18, Section 180.2) Also see Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N). 

FAQ 6. What are the specific requirements for the Alcohol and substance abuse screening and counseling codes?

The physician or healthcare provider will initially employ evidence-based questionnaires to screen for alcohol or tobacco problems. The AUDIT, DAST and T-ACE questionnaires are examples of standard screening tools.  Examples of evidence-based screening tools and resource materials can be found online.  One resource for screening tools: 

http://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/screening-assessment-drug-testing-resources/chart-evidence-based-screening-tools-adults

Document time spent counseling the patient about alcohol or other non-tobacco substance abuse.  Alcohol/Substance abuse counseling codes are time based. Once the patient has been screened, a brief intervention (15-30 minutes) or extended counseling (> 30 minutes) is performed to increase the probability the patient will abstain or reduce their intake of alcohol or other non-tobacco substances, and address the problems. These codes require a significant amount of time and counseling beyond general advice provided to patients. The services involve distinct clinical assessments and procedures intended to elicit behavioral change for problematic alcohol or substance use. 

FAQ 7. What is the reimbursement for these codes?

Reimbursement for Medicare and many other payers is determined by the RVUs assigned to the code.  The RVUs assigned to these services in 2016 are:

 

Code

Work

PE

Malpractice PLI

Total RVU

99406

0.24

0.09

0.02

0.35

99407

0.50

0.19

0.04

0.73

99408

0.65

0.25

0.04

0.94

99409

1.30

0.50

0.08

1.88

G0396

0.65

0.25

0.05

0.95

G0397

1.30

0.55

0.08

1.93

 

The Medicare payment is determined by multiplying the RVUs by the Conversion Factor. At this writing, the CF for  2017 is  $35.89.

FAQ 8. Will private payers and Medicare recognize and reimburse these codes?

The smoking cessation codes (99406 and 99407) have been assigned status indicator A in the Physician Fee schedule and as such are reportable to Medicare. Medicare has assigned two HCPCS G-codes, G0396 (15-30 minutes) and G0397 (>30 minutes), to report Alcohol and substance intervention. You are advised to check with your local payers to determine the coverage for these codes.

 

For additional information on Alcohol and substance abuse screening codes:

http://www.integration.samhsa.gov/clinical-practice/SBIRT.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1013.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ICN904084.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

 

 

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org 

 Updated 02/24/2017

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