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Behavior Change Intervention FAQ

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

    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.

    Answer

    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.

  • May I also report an ED E/M on the same date of service as these services?
    Recommendations
    Answer

    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.

    Answer

    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.

  • What are the specific codes to report smoking/tobacco abuse screening and counseling services?
    Recommendations
    Answer

    99406

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

    99407

    Intensive, greater than 10 minutes

    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/medicare-preventive-services/MPS-QuickReferenceChart-1.html#TOBACCO

    Answer

    99406

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

    99407

    Intensive, greater than 10 minutes

    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/medicare-preventive-services/MPS-QuickReferenceChart-1.html#TOBACCO

  • What are the specific requirements and RVU for the smoking/tobacco abuse screening and counseling codes?
    Recommendations
    Answer

    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

    0.10

    .02

    0.36

    99407

    0.50

    0.20

    0.04

    0.74



    Answer

    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

    0.10

    .02

    0.36

    99407

    0.50

    0.20

    0.04

    0.74



  • What are the specific codes and requirements to report alcohol and/or substance abuse services?

    Recommendations
    Answer

    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 may 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).

    Answer

    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 may 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).

  • What is the reimbursement for these codes?

    Recommendations
    Answer

    The RVUs assigned to smoking and tobacco AUDIT/ DAST use cessation services in 2020 are:

    HCPCS

    Work

    PE

    MP

    Total RVUs

    99408

    0.65

    0.25

    0.05

    0.95

    99409

    1.30

    0.50

    0.11

    1.91

    G0396

    0.65

    0.24

    0.05

    0.94

    G0397

    1.30

    0.44

    0.11

    1.85

    The Medicare payment is determined by multiplying the RVUs by the Conversion Factor. At this writing, the CF for 2020 is 36.0896

    Answer

    The RVUs assigned to smoking and tobacco AUDIT/ DAST use cessation services in 2020 are:

    HCPCS

    Work

    PE

    MP

    Total RVUs

    99408

    0.65

    0.25

    0.05

    0.95

    99409

    1.30

    0.50

    0.11

    1.91

    G0396

    0.65

    0.24

    0.05

    0.94

    G0397

    1.30

    0.44

    0.11

    1.85

    The Medicare payment is determined by multiplying the RVUs by the Conversion Factor. At this writing, the CF for 2020 is 36.0896

  • Will private payers and Medicare recognize and reimburse these codes?

    Recommendations
    Answer

    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 with the following parameters:

    Medicare Covers

    Outpatient and hospitalized patients for whom all are true:

    • Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
    • Competent and alert at the time of counseling
    • Counseling provided by a qualified physician or other Medicare-recognized practitioner

    Alcohol abuse codes are payable for primary care settings only.

    Answer

    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 with the following parameters:

    Medicare Covers

    Outpatient and hospitalized patients for whom all are true:

    • Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
    • Competent and alert at the time of counseling
    • Counseling provided by a qualified physician or other Medicare-recognized practitioner

    Alcohol abuse codes are payable for primary care settings only.

  • Are there codes and guidelines for opioid counseling?

    Recommendations
    Answer

    Starting January 1, 2020, under the Calendar Year (CY) 2020 Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) added Opioid Treatment Programs (OTPs) through bundled payments for opioid use disorder (OUD) treatment services provided to people with Medicare Part B (Medical Insurance). 

    Under the OTP benefit, Medicare covers:

    • U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications
    • Dispensing and administration of MAT medications (if applicable)
    • Substance use counseling
    • Individual and group therapy
    • Toxicology testing
    • Intake activities
    • Periodic assessments

    There are HCPCS codes for Office-based, Telehealth opioid treatment (G2086-G2088).  These codes reflect monthly bundled services for primary care. 

    Who can provide OTP services? OTP providers must be:

    • Enrolled in Medicare
    • Fully certified by SAMHSA
    • Accredited by an accrediting body approved by SAMHSA
    • Able to meet such additional conditions as the Secretary may find necessary to ensure the health and safety of individuals being provided services

    Professionals who can provide the substance use counseling and individual and group therapy included in the bundled payment may include:

    • Licensed clinical social workers
    • Licensed professional counselors
    • Licensed clinical alcohol and drug counselors
    • Certified peer specialists who are permitted to furnish this type of therapy or counseling by state law and scope of practice
    • Others who are permitted to furnish this type of therapy or counseling by state law and scope of practice

    If the individuals furnishing therapy or counseling services are not authorized under state law to furnish such services, the therapy or counseling services provided by these professionals would not be covered as OUD treatment services.  Source:  https://www.cms.gov/files/document/otp-billing-and-payment-fact-sheet.pdf

    The 2021 Physician Fee Schedule includes HCPCS codes G2067-G2080 for the treatment of opioid dependence.  These codes carry a status indicator A, which includes payment under the Medicare Physician Fee Schedule. 

    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

    See also Federal Guidelines for Opioid Treatment Programs https://store.samhsa.gov/system/files/pep15-fedguideotp.pdf

    Answer

    Starting January 1, 2020, under the Calendar Year (CY) 2020 Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) added Opioid Treatment Programs (OTPs) through bundled payments for opioid use disorder (OUD) treatment services provided to people with Medicare Part B (Medical Insurance). 

    Under the OTP benefit, Medicare covers:

    • U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications
    • Dispensing and administration of MAT medications (if applicable)
    • Substance use counseling
    • Individual and group therapy
    • Toxicology testing
    • Intake activities
    • Periodic assessments

    There are HCPCS codes for Office-based, Telehealth opioid treatment (G2086-G2088).  These codes reflect monthly bundled services for primary care. 

    Who can provide OTP services? OTP providers must be:

    • Enrolled in Medicare
    • Fully certified by SAMHSA
    • Accredited by an accrediting body approved by SAMHSA
    • Able to meet such additional conditions as the Secretary may find necessary to ensure the health and safety of individuals being provided services

    Professionals who can provide the substance use counseling and individual and group therapy included in the bundled payment may include:

    • Licensed clinical social workers
    • Licensed professional counselors
    • Licensed clinical alcohol and drug counselors
    • Certified peer specialists who are permitted to furnish this type of therapy or counseling by state law and scope of practice
    • Others who are permitted to furnish this type of therapy or counseling by state law and scope of practice

    If the individuals furnishing therapy or counseling services are not authorized under state law to furnish such services, the therapy or counseling services provided by these professionals would not be covered as OUD treatment services.  Source:  https://www.cms.gov/files/document/otp-billing-and-payment-fact-sheet.pdf

    The 2021 Physician Fee Schedule includes HCPCS codes G2067-G2080 for the treatment of opioid dependence.  These codes carry a status indicator A, which includes payment under the Medicare Physician Fee Schedule. 

    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

    See also Federal Guidelines for Opioid Treatment Programs https://store.samhsa.gov/system/files/pep15-fedguideotp.pdf

Updated January 2021

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, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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