Medicare Reimbursement Codes for Alcohol Misuse and Depression Screening

CMS sponsored a conference call last week to make sure that Part B providers are aware of new services payable by Medicare. These services were in effect late in 2011, but most providers are not aware of their existence. Is your practice using these new Medicare reimbursement codes?Doctor and Patient Drug And Alcohol Abuse Screening

Screening & Counseling for Alcohol Misuse

Why does CMS consider alcohol misuse screening and counseling important for Medicare patients?

According to the USPSTF (2004), alcohol misuse includes risky/hazardous and harmful drinking which place individuals at risk for future problems; and in the general adult population, risky or hazardous drinking is defined as >7 drinks per week or >3 drinks per occasion for women, and >14 drinks per week or >4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing physical, social or psychological harm from alcohol use, but who do not meet criteria for dependence.

Which providers can provide alcohol misuse screening and counseling for Medicare patients?

  • 08-Family Practice
  • 11-Internal Medicine
  • 16-Obstetrics/Gynecology
  • 37-Pediatric Medicine
  • 38-Geriatric Medicine
  • 42-Certified Nurse Midwife
  • 50-Nurse Practitioner
  • 89-Certified Clinical Nurse Specialist
  • 97-Physician Assistant

New code G0442 – screening for alcohol misuse, is available once every 12 months, 15 minutes

National Payment Rates

  • $17.36 Physician (non-facility)
  • $9.19 Physician (facility)
  • $35.69 Hospital/Outpatient
  • No beneficiary co-insurance/deductible

New code G0443 – Brief face-to-face behavioral counseling, is available four times every 12 months, 15 minutes each visit

Each of the four behavioral counseling interventions must be consistent with the 5As approach that has been adopted by the USPSTF to describe such services:

  1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

National Payment Rates

  • $25.19 Physician (non-facility)
  • $23.15 Physician (facility)
  • $35.69 Hospital/Outpatient
  • No beneficiary co-insurance/deductible

Can this service be provided at the same time as another service? Typically it would be bundled into another visit (such as the patient coming in to discuss a problem with alcohol), however, it can be provided at the same time but charged additionally to a Welcome to Medicare Visit (G0402) and services with modifier 59. Modifier 59 may be used when procedures (not E/M codes) that are normally bundled should both be reported because of a specific circumstance.

Screening for Depression

New Code G0444 – Annual depression screening, no more than once in a 12-month period

Why does CMS consider depression screening important for Medicare patients?

Among persons older than 65 years, one in six suffers from depression. Depression in older adults is estimated to occur in 25% of those with other illness including cancer, arthritis, stroke, chronic lung disease, and cardiovascular disease. Other stressful events, such as the loss of friends and loved ones, are also risk factors for depression. Opportunities are missed to improve health outcomes when mental illness is under-recognized and under-treated in primary care settings. Older adults have the highest risk of suicide of all age groups. These patients are important in the primary care setting because 50-75% of older adults who commit suicide saw their medical doctor during the prior month for general medical care, and 39% were seen during the week prior to their death. Symptoms of major depression that are felt nearly every day include, but are not limited to, feeling sad or empty; less interest in daily activities; weight loss or gain when not dieting; less ability to think or concentrate; tearfulness, feelings of worthlessness, and thoughts of death or suicide.

Who can provide depression screening for Medicare patients?

This service must be provided in a primary care setting, as defined below, that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. For the purposes of this NCD, a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospice are not considered primary care settings under this definition.

What tool does Medicare want providers to use for depression screening?

Various screening tools are available for screening for depression. CMS does not identify specific depression screening tools. Rather, the decision to use a specific tool is at the discretion of the clinician in a primary care setting.

Does Medicare cover treatment for depression under this code or related codes?

Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medications), or other interventions for depression. Self-help materials, telephone calls, and web-based counseling are not separately reimbursable by Medicare and are not part of this NCD. Note: Eleven full months must elapse following the month in which the last annual depression screening took place. National Payment Rates

  • $17.36 Physician (non-facility)
  • $9.19 Physician (facility)
  • $35.69 Hospital/Outpatient
  • No beneficiary co-insurance/deductible

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