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New SBI Codes, Dollar Values, for Medicare, Private Insurance

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Physicians now have four different codes that can be used in 2008 for screening and brief intervention (SBI). These codes are a victory for the addiction field, and especially for the sponsors, with Ensuring Solutions to Alcohol Problems, a Washington, D.C.-based advocacy group, leading the way.

Two of the codes are for privately insured patients (99408 and 99409), and two for Medicare patients (G0396 and G0397), and they have fees: for 15-30 minutes, Medicare will pay about $22, unadjusted for geographic location, and private payers who cover the services could pay even more; for more than 30 minutes, Medicare will pay $55 and private payers could pay more.

“The most important step now is to get our CPT [Current Procedural Terminology] codes, and the G codes for Medicare, used and used appropriately,” Eric Goplerud, Ph.D., director of Ensuring Solutions, told Alcoholism and Drug Abuse Weekly (ADAW).

In addition to Ensuring Solutions, groups who worked on getting the SBI codes into the coding nomenclature include the White House Office of National Drug Control Policy (ONDCP), Physicians and Lawyers for National Drug Policy, and the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration. This is the same group that obtained SBI codes for Medicaid last year (see ADAW Sept. 25, 2006). The SBI H codes for Medicaid are H0049 and H0050.

CPT codes are published in a manual each year by the American Medical Association. These codes are used to bill insurance companies – and Medicare – for services provided by physicians and other health care providers. The fact that SBI codes 99408 and 99409 are in the 2008 CPT manual means that physicians have a way to bill for screening.

Also every year, Medicare publishes its physician fee schedule which lists the payable amounts for each CPT code, and also for special Medicare-only HCPCS codes such as the G codes.

In the fee schedule for 2008, released by CMS [Centers for Medicare & Medicaid Services] Nov. 1, Medicare says it won't pay for the CPT codes because they include screening, and by statute Medicare cannot pay for screening. However, instead of just turning its back on the services – as Medicare does with other codes it deems non-coverable – the program created two new codes called G codes which will allow doctors to bill Medicare for SBI.

“They literally created new codes, and that shows a profound commitment to the screening and brief intervention services,” Bertha Madras, Ph.D., ONDCP's deputy director for demand reduction, told ADAW.

More addiction patients

Addiction treatment is likely to get many more patients if SBI coding is successful. For trauma centers, the incidence of risky substance use is 35-45 percent, according to Larry M. Gentilello, M.D., the University of Texas professor and trauma surgeon who showed the medical coding people the wisdom of paying for SBI. For emergency departments, the incidence of risky substance use is 25-35 percent.

Some of these people will need more than a brief intervention, and whatever incident got them into the emergency or trauma department – bleeding ulcer, drunk driving accident, etc. – may be the precipitating factor for getting them into treatment. In addition, SBI conducted in primary care will result in new patients for addiction treatment as well.

The federal Screening, Brief Intervention, Referral and Treatment (SBIRT) programs that are funded through SAMHSA have shown that of everyone screened, 20 percent are positive for risky, problematic substance use, said Madras. Of that 20 percent, 70 percent can be treated by a single brief intervention, 15 percent need six or fewer follow-up interventions that can be done by telephone, and 15 percent have dependence and need specialty substance abuse treatment, she said.

Under the fee schedule, 99408 or G0396 (15-30 minutes) would pay $22. Code 99409 or G0397 (more than 30 minutes) would pay $55.

“We know that private payers use our fee schedule, which is why we published the values for those codes on our fee schedule,” said a Medicare official familiar with the final rule.

For patients not covered by Medicare – in other words, patients under age 65 – the only codes physicians can use are the CPT codes. Private payers have yet to weigh in on whether they will cover these codes. But Medicare made it much easier for them to do so by publishing the RVUs (relative value units) for the CPT codes. These RVUs, when multiplied by the conversion factor, give the dollar amount payable per code. Since most payers rely on the Medicare fee schedule, at least as a jumping off point to set their own fees, the publishing of RVUs makes it much more likely that non-Medicare patients will get these services as well.

The G codes

In creating the new G codes, Medicare changed the definition of the SBI codes somewhat. The definition of the Category I CPT codes reads “Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services.” Medicare, in the Nov. 1 Federal Register final rule for the physician fee schedule, said these descriptions “suggest that these CPT codes may describe services that include screening services.” Screening services are those services provided in the absence of signs or symptoms, and are not allowed to be covered by Medicare without specific authority (as in the case of mammograms).

“Accordingly, we will not recognize these CPT codes that incorporate screening for payment,” the final rule says, noting that the CPT codes have a status of “N” for noncovered. “Instead, we have created two parallel G-codes to allow for appropriate Medicare reporting and payment for alcohol and substance abuse assessment and intervention services that are not provided as screening services, but that are performed in the context of the diagnosis or treatment of illness or injury.”

The definitions of the HCPCS codes focus on “assessment” instead of “screening.” These codes, again, will only be used for people age 65 and above. The G-code definitions are “Alcohol and/or substance (other than tobacco) abuse structured assessment (eg, AUDIT, DAST) and brief intervention, 15-30 minutes” for G0396, and “Alcohol and/or substance (other than tobacco) abuse structured assessment (eg, AUDIT, DAST) and intervention, greater than 30 minutes” for G0397. Note that Medicare calls the 15-30 minute intervention “brief,” but does not use that same denomination for the longer intervention. The G codes also are defined as “assessment” instead of “screening. Medicare will instruct its carriers to pay for G0396 and G0397 “only when considered reasonable and necessary.”

It may seem picayune, but coding definitions drive reimbursement. The redefinition by Medicare in the G codes sets the stage for a future discussion of the difference between “assessment” – which implies there is a problem that is being assessed – and “screening.” However, Ensuring Solutions and the other CPT code sponsors are happy with the Medicare “workaround” using the G codes.

“At the present time there are no plans to file for new descriptors for the Category I codes,” said Goplerud. “Our next plans involve helping physicians and coders to use the new CPT and G codes correctly, to learn as much as we can about how they are being implemented and any challenges encountered, and possibly submitting for Category II tracking codes as we recognize that many physicians and other health professions can use other CPT and HCPCS codes to describe SBI services that they may provide while doing other procedures.” Tracking codes are Category III codes that are nonpayable, but that may help gauge utilization of these services.

Trauma and emergency first

“My view of these codes is that first and foremost, they should be broadly applied in emergency and trauma departments,” said the ONDCP's Madras, formerly Associate Director for Public Education in the Division on Addictions at Harvard Medical School. “There should be a screening person who is dedicated to this procedure, who implements it universally for all patients who come in.” Emergency and trauma departments should be a priority for SBI codes because rates of risky substance use are higher in these sites than in the general medical population, she said.

Madras added that SBI should also be performed in primary care, but she acknowledged that more needs to be done. “It's been estimated that there are 90 preventive services that have been recommended, and if a physician would do all of them, it would take up seven additional hours each day.” What primary care physicians need are “prevention teams,” said Madras. In the meantime, however, physicians should still be screening their patients and intervening when necessary. “What the intervention is designed to do is in the case of illicit drugs, simply advise through dialogue to eliminate drug use, which prevents consequences,” she said. “With regard to alcohol, the advice is to cut down, cut down, cut down.”

Reprinted with permission from Alcoholism and Drug Abuse Weekly, a publication offering news and analysis of federal and state public policy developments, private sector business developments and provider issues and innovations.

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