Pain Management, Addiction Medicine Coding, Billing Expert Provides Guidance to Comply with Medical Necessity, Medical Coding, Medical Billing and Controlled Substances Act Requirements
In 2007, new Standards were introduced that assist Pain Management, Behavioral Health, and Addiction Medicine specialists to maximize legitimate reimbursement for substance abuse screenings, and brief interventions. It may seem counter-intuitive at first, but two CPT codes used for screening where no symptoms are present will not result in reimbursement. Providers must use the appropriate HCPCS G-codes. This article examines those CPT codes used to indicate screening and the mapping that is sometimes required to HCPCS codes for reimbursement. Also, examples of recent updates to State Medicaid Standards are provided as of 2018. The CDC also recommends that primary care physicians implement screening and brief intervention (SBI) methods into their practice.
Patients who take addictive medications such as opiates for chronic pain are at risk of developing an addiction. Therefore, preventive care is especially useful in pain practices. The spectrum of care generally starts with either a screening in the case of proactive care or at the other extreme, court-ordered treatment after a life event. This post examines some of the billing and reimbursement issues related to screening and touches upon the behavioral health care and toxicology/drug screening that may also be a component of post-assessment care.
Category I CPT codes for reporting alcohol and Substance abuse Screening
These codes have been in use for over a decade but are still valid and current as of 2019:
- 99408 (alcohol and/or substance (other than tobacco) structured abuse screening (see DAST below) and alcohol brief intervention (see SBI below) services; 15 to 30 minutes) and
- 99409 (alcohol and/or substance (other than tobacco) structured abuse screening (see DAST below) and alcohol brief intervention (see SBI below) services; greater than 30 minutes).
The code descriptions for these CPT codes include “screening.” Screening services under Medicare are provided to beneficiaries in the absence of signs or symptoms of illness or injury. “Therefore, to the extent that the services described by these two CPT codes have a screening element, the screening component would not meet the statutory requirements for coverage under Section 1862 (a) (1) (A) of the Act,” according to the 2008 Medicare Physician Fee Schedule. Medicare does not recognize these CPT codes that include screening for payment.
As a result, Medicare will not recognize these CPT codes for payment. Instead, it has 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 are performed in the context of the diagnosis or treatment of illness or injury.
Getting Reimbursed by Medicare, Medicaid and Private Payors for Alcohol and Substance Abuse Screenings
CMS assigned a status indicator of “N” (non covered) to CPT codes 99408 and 99409. The work RVUs and practice expense (PE) inputs for 99408 are mapped or cross walked to G0396, and the work RVUs and PE inputs for 99409 are cross walked to G0397.
Therefore these HCPCS codes are used for billing for and getting reimbursed for the services codes 99408 and 99409. These codes have been in use for over a decade but are still valid and current as of 2019:
- G0396 (alcohol and/or substance (other than tobacco) structured abuse assessment and brief intervention, 15 to 30 minutes) and
- G0397 (alcohol and/or substance (other than tobacco) abuse structured assessment and intervention greater than 30 minutes).
The Medical Necessity Test
CMS states in its guidance: “We will instruct Medicare contractors to pay for these codes only when considered reasonable and necessary. We will also provide coding and payment instructions for these assessment and intervention services in the program instructions to implement the CY 2008 PFS.” See the DAST Screening, below.
State Medicaid Coding Standards for Substance Use Disorder
CMS published Level II HCPCS codes for alcohol and drug screening that became effective January 2007. States can choose whether to adopt the Medicaid codes and reimburse for the services. (See Note 1, below).
- H0049 Alcohol/Drug Screening
- H0050 Alcohol/Drug Service 15 minutes – Alcohol and or Drug Service, Brief Intervention, per 15 minutes
Substance Abuse Services are a Good Investment for Society
Frequently, treatment for substance abuse starts with the legal system. However, since new guidelines on medical coding and services for substance abuse, we are applying medical instantiation of behavioral health conditions that had a prior stigma of being the fault of the patient, rather than treating the condition as a disease.
Approximately 95 percent of the 22 million Americans who abuse or are addicted to drugs or alcohol are unaware that they had a medical problem. Therefore, they do not seek treatment. Widespread screening can reduce adverse effects on the brain and body, and brief interventions can be reliable, cost-effective, and long-lasting. There are estimates that for each dollar spent on substance abuse services, the health care system saves about $4. Early detection and intervention have been effective in stopping substance abuse behavior before it can progress to the addiction stage. (See New substance abuse codes may aid in addiction prevention (2007). DecisionHealth, 2007; Published December 1, 2007).
According to the Centers for Disease Prevention and Control (CDC), Excessive Alcohol Use is Common:
- Binge Drinking†—More than 37 million American adults binge drink.
- Heavy Drinking*— In 2013, according to the Behavioral Risk Factor Surveillance System survey, about 6 percent of the adult population reported heavy drinking.
- Pregnant Women*—During 2015–2017, 1 in 9 (11.5%) pregnant women aged 18–44 years in the United States reported drinking alcohol in the past 30 days. Among pregnant women who reported consuming alcohol, one-third engaged in binge drinking.3
- Youth under 21 years of age*—In 2017, 60.4 percent of high school students had at least one drink of alcohol, on at least one day during their life (i.e. ever drank alcohol).
Screening and Brief Interventions (SBI)
Alcohol SBI is a preventive service, like blood pressure or cholesterol screening, which can occur as part of a patient’s wellness visit. It identifies and helps individuals who are drinking above recommended amounts. Alcohol SBI involves
- A validated set of screening questions, which only take a few minutes, to identify patients’ drinking patterns; and
- A short conversation with patients who are drinking above recommended amounts, as well as referral to treatment when appropriate.
Addiction Rehabilitation Treatment
After an assessment, various levels of care are provided for in Federal and State Guidelines based on medical necessity. The services include a continuum of care based on the American Society of Addiction Medicine (ASAM) criteria, which ensures clients may enter substance use disorder (SUD) treatment at a level that is appropriate to their needs, and step up or down to a different intensity of treatment based on their responses. In California, for example, Medicaid beneficiaries receive care based on the ASAM criteria.
Intensive Outpatient Treatment (ASAM Level 2.1) for Substance Use Disorder
Structured programming services are provided to beneficiaries a minimum of nine hours with a maximum of 19 hours a week for adults, and a minimum of six hours with a maximum of 19 hours a week for adolescents. Services consist of intake, individual and/or group counseling, patient education, family therapy, medication services, collateral services, crisis intervention, treatment planning, and discharge services. One unit of service is equal to a 15-minute increment. Claims may be submitted with either minutes or fractional units of service. Units of service for group counseling should be calculated using the same formula as described in outpatient services.
Partial Hospitalization (ASAM Level 2.5) for Substance Use Disorder
Services feature 20 or more hours of clinically intensive programming per week. Level 2.5 partial hospitalization programs typically have direct access to psychiatric, medical, and laboratory services, and are to meet the identified patient needs which require daily management but that can be appropriately addressed in a structured outpatient setting. Services consist of intake, individual and/or group counseling, patient education, family therapy, medication services, collateral services, crisis intervention, treatment planning, and discharge services.
Residential Treatment (ASAM Level 3.1, 3.3, and 3.5) for Substance Abuse
This treatment is a non-institutional, 24-hour non-medical, short-term program that provides rehabilitation services which includes intake, individual and group counseling, patient education, family therapy demonstration approval, safeguarding medications, collateral services, crisis intervention, treatment planning, transportation services, and discharge services. Residential services may be provided to non-perinatal and perinatal beneficiaries in facilities with no bed capacity limit.
Withdrawal Management (Levels 1, 2, and 3.2) for Substance Abuse
Withdrawal Management services include intake, observation, medication services, and discharge services. Counties must be certified to provide residential detoxification or non-residential detoxification services. Contact DHCS SUD Compliance Division at (916) 322-2911 for questions regarding certification for this service.
Opioid (Narcotic) Treatment Program (ASAM OTP Level 1)
NTPs/OTPs are required to offer and prescribe medications to patients covered under the DMC-ODS Waiver; including Methadone, Buprenorphine, Naloxone and Disulfiram. A National Drug Code (NDC) is required on the 837P for Buprenorphine, Naloxone, and Disulfiram, not for Methadone.
Additional Medication-Assisted Treatment (ASAM OTP Level 1)
This treatment includes ordering, prescribing, administering, and monitoring of all medications for SUDs.
Counties may choose to utilize long-acting injectable naltrexone in allowable DMC facilities. Long-acting injectable Naltrexone will be reimbursed for onsite administration, however, counties must cover the non-federal share cost. Counties may set the rate for specific medications such as Buprenorphine, Disulfiram, Naloxone, Vivitrol, and Acamprosate. NDCs for these medications are required on the 837P.
Additionally, physicians and licensed prescribers in DMC programs will be reimbursed for the ordering, prescribing, administering, and monitoring of medication-assisted treatment. One unit of service is equal to a 15-minute increment. Claims may be submitted with either minutes or fractional units of service.
The components of recovery services are outpatient counseling services, recovery monitoring, substance abuse assistance, education and job skills, family support, support groups, and ancillary services. Recovery services may be billed for individual and group counseling, case management, and recovery monitoring/substance abuse assistance. One unit of service is equal to a 15-minute increment. Claims may be submitted with either minutes or fractional units of service. Units of service for group counseling should be calculated using the same formula as described in outpatient services.
Case management is a service that assists a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. Case management services include comprehensive assessment and periodic reassessment of individual needs to determine the need for continuation of case management services; transition to a higher or lower level SUD of care; development and periodic revision of a client plan that includes service activities; communication, coordination, referral, and related activities; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring the beneficiary’s progress; patient advocacy, linkages to physical and mental health care, transportation and retention in primary care services. One unit of service is equal to a 15-minute increment. Claims may be submitted with either minutes or fractional units of service
Other Treatment Service Codes
Post Assessment, if a patient is referred to additional treatment the options may include intensive outpatient (IOP) or inpatient treatment. The treatment is likely to include counseling, using such codes as:
4306F Patient counseled regarding psychosocial and pharmacologic treatment options for opioid addiction
Naltrexone Treatment Services
Certain state Medicaid guidelines and coverage determinations provide for Naltrexone treatment services including intake, admission physical examinations, treatment planning, provision of medication services, medical direction, physician and nursing services related to substance abuse, body specimen screens, individual and group counseling, collateral services, and crisis intervention services, provided by staff that are lawfully authorized to provide, prescribe and/or order these services within the scope of their practice or licensure. These services are only reimbursable under the DMC Program for a beneficiary who has a confirmed, documented history of opiate addiction; is at least 18 years of age; is opiate free; and is not pregnant.
Court-ordered treatments or treatment and parole arrangements may include toxicology screenings using such codes as:
80300 – Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (eg, dipsticks, cups, cards, cartridges), per date of service.
Payer Policies Regarding Determination of Medical Necessity and Reimbursement
The Centers for Medicare and Medicaid (CMS) issues policies for Medicare beneficiaries. These are often adopted by State Medicaid payers as well as commercial payers, but policies may vary.
State Licensure and Other Requirements
Generally, addiction treatment facilities are also required to obtain:
- A national provider identifier (NPI) number
- In jurisdictions such as California, State alcohol and other drug (AOD) certification is granted to programs that exceed minimum levels of quality service and are in substantial compliance with state program standards, specifically the alcohol and/or other drug certification standards. The California Department of Health Care Services recognizes the following National Commission for Certifying Agencies (NCCA) accredited organizations to register and certify alcohol and other drug counselors
- Narcotic Treatment or Residential Facility licensure (mandatory)
- Voluntary Alcohol and Other Drug Certification
Controlled Substances Act and Drug Diversion, Effective Controls of Registrants who Distribute Opioids and other Schedule II Drugs