Screening, Brief Intervention and Referral-to-Treatment SBIRT Billing

1
Screening, Brief Intervention and
Referral-to-TreatmentSBIRT Billing Getting Paid

• Presented by Penny Osmon, BA, CHC, CPC, CPC-I,
  PCS
• Coding Reimbursement Educator
• Wisconsin Medical Society
• Penny.osmon_at_wismed.org

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Objectives

• Participants will learn how to bill for SBIRT
  services when performed with other services on
  the same day.
• Participants will have an understanding of
  documentation requirements for reimbursement.
• Participants will learn when to append modifiers.
• Participants will gain knowledge of various
  reimbursement models for federal and commercial
  payers.

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Reimbursement for SBIRT

• Resource Based Relative Value Scale (RBRVS)
• Relative Value Units (RVU)
• Used by Medicare and HMOs to establish rates
• Medicaid has fee schedule amounts based on
  rendering provider type

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Reimbursement for SBIRT
SBIRT Work RVU Total Facility RVU Total Non-Facility RVU
99408 G0396 .65 .82 .86
99409 G0397 1.30 1.64 1.68
99211 Medicare .17 .24 .52
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Reimbursement for SBIRT

• Medicaid
• H0002 (pregnant)
• 35.35
• H0004 (pregnant)
• 20.23
• 99212 (non-pregnant)
• No modifier 21.96
• HPSA modifier
• Under 18 28.37
• Over 18 26.35
• TJ modifier
• 23.65

• Medicare
• G0396
• Facility 30.23
• Non-Facility 28.91
• G0397
• Facility 57.63
• Non-Facility 58.96
• 99211
• Facility 8.27
• Non-Facility 17.57
• 85 if reported by PA/NP

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Reimbursement for SBIRT

• Commercial Payers
• 99408 averages 33.41
• 99409 averages 65.51
• Diagnosis code for best practice
• V82.9, Screening for unspecified condition

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Some Medicaid Need to Knows
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Health Professional Shortage Area (HPSA)

• Enhanced reimbursement
• Primary Care and ED
• Based on address of
• Either the billing provider, or
• The enrolled members address
• Incentive is an additional 20 of the maximum fee
  amount
• Requires modifier AQ

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TJ Modifier

• Medicaid only
• Enhances payment for pediatric services
• Applied to CPT 99201 99215
• Patient under age 18
• Applies specifically for SBIRT when 99211 or
  99212 is billed for services by a health educator

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Documentation Requirements

• Name of the patient
• Who provided the service
• The purpose/need for the service
• (medical necessity or reason)
• Accurate description of the service
• Legible if hand written
• Date of service and place of service
• Quantity and level of service

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Health Educator is the Provider

• Medicaid
• Billing under E/M codes as ancillary provider
  type using CPT 99211 or 99212
• Medicare
• Bill Incident-to using CPT 99211
• Commercial Payers
• SBIRT codes under supervision
• Is it mental health benefit or medical benefit?

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Ancillary Provider Guidelines

• Medicaid rules include
• Direct, immediate, on-site supervision of a
  physician
• Services are pursuant to the plan of care
• The supervising physician has not also provided
  Medicaid reimbursable service during the same
  office or outpatient EM
• Cant bill in addition to or combine the services
• Health educators meet the definition of ancillary
  provider

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Ancillary Provider Guidelines

• Claims are submitted to Medicaid using the
  supervising physicians NPI
• Using the lowest appropriate level office visit
  CPT code for the services performed, typically a
  99211 or 99212
• Supervising physician is rendering provider

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99211 and 99212

• 99211 Office or other outpatient visit for the
  evaluation and management of an established
  patient, that may not require the presence of a
  physician. Usually, the presenting problem(s) are
  minimal. Typically, 5 minutes are spent
  performing or supervising these services.

Source CPT Professional Edition ,2009
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99211 and 99212

• 99212 Office or other outpatient visit for the
  evaluation and management of an established
  patient, which requires at least 2 of these 3 key
  components
• A problem focused history
• A problem focused exam
• Straightforward medical decision making
• Usually, the presenting problem(s) are self
  limited or minor. Physicians typically spend 10
  minutes face to face with the patient and/or
  family.

Source CPT Professional Edition ,2009
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Billing with Evaluation and Management (EM)
Codes
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Evaluation Management (EM) Elements

• History, Exam and Medical Decision Making
• Need 3 of 3 for new patients (99201 99205)
• Need 2 of 3 for established patients
• (99211 -99215)

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Evaluation Management (EM) Elements

• Or may report based on time
• Greater than 50 of visit must be counseling
  and/or coordination of care
• Documentation is key!
• Both time and what the counseling entailed
• Example I spent 15 minutes with the patient
  today and all 15 minutes were used counseling the
  patient on potential risk behaviors.
• The note should include the nature of the
  counseling

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Billing with E/M Codes

• Physicians are typically defined by specialty and
  group
• All physicians within the same specialty, same
  group 1 physician for billing purposes
• Example Two primary care physicians provide two
  EM services on the same day to the same patient,
  only one EM can be billed, combining
  documentation

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Multiple Services on the Same Day

• Physicians can bill for an EM and the provision
  of SBIRT services on the same day when personally
  performing the services
• Example 99214 (EM, established patient)
  99408 (SBIRT for commercial payer)
• Example 99203 (EM, new patient) G0396 (SBIRT
  for Medicare)

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Multiple Services on the Same Day

• EM would be billed based on the 3 elements or on
  time and counseling/coordination of care
• Commercial payers will reimburse health educator
  services on the same day under supervision
• Only historical elements from the health educator
  could be included in the level of service
• Past family, social, medical history, and
• Review of systems
• For Medicare

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Historical Information

• For purposes of SBIRT may include
• Historical information gathered during alcohol
  and drug screening and assessment

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Example

• 50-year-old male seen for unscheduled visit for
  cold symptoms and wheezing. History of acid
  reflux, headaches, mild hypertension, alcoholism
  in three first-degree relatives. The patient
  recently lost his job, and uses alcohol socially
  several times per week.
• DX URI, prescribed an inhaled beta-2 agonist.
  The physician assessed risk of alcohol use
  disorder with a standard 10-item AUDIT
  questionnaire. Patient provided feedback about
  drinking and medical concern, generated option to
  reduce drinking, developed plan and commitment to
  change. Greater than 30 minutes of SBI.
• EM and 99409 may be billed

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Example

• Patient presents for an annual preventive exam.
  During the exam, physician performs a CAGE survey
  to assess alcohol abuse as protocol. Patient is
  referred to an alcohol program. Twenty minutes is
  spent convincing the patient there is a drinking
  problem.
• The service described does not sound like
  specific SBI interventions, but may be reported
  with an EM.

AMA CPT Symposium, November 2007
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Site of Service Matters
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SBIRT in the ED

• CPT codes are
• 99281-99285
• SBIRT may be billed in addition when performed by
  a credentialed provider
• 99408, 99409, G0396, G0397
• Would be rare for separate payment to health
  educator

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SBIRT in the FQHC

• Same billing requirements as the office
• Reimbursement will be encounter rate and is all
  inclusive
• Encounters with more than one health professional
  and multiple encounters with the same health
  professionals which take place on the same day
  and at a single location constitute a single
  visit, except when one of the following
  conditions exist
• (a) after the first encounter, the patient
  suffers illness or injury requiring additional
  diagnosis or treatment
• (b) the patient has a medical visit and a
  clinical psychologist or clinical social worker
  visit.

Source IOM 100-09, Chapter 1, Section 20.1
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SBIRT in the Hospital

• Inpatient
• Facility fee DRG
• No separate payment, bundled in
• Professional fee
• E/M (99221-99223 or 99231-99233) and SBIRT codes
• No separate payment for health educator when
  employed by facility

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SBIRT in the Hospital

• Inpatient
• Facility fee DRG
• No separate payment, bundled in
• Professional fee
• E/M (99221-99223 or 99231-99233) and SBIRT codes
• No separate payment for health educator

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Commercial Payer Reimbursement

• The verdict is out
• Several have been asked to consider payment when
  performed by a health educator
• STAY TUNED!

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Commercial Payer Information

• Anthem 99408 99409 are covered
• Processed under medical benefit for Wisconsin
  insured members
• No payment if billed with preventive CPT codes
  99381-99387 99391-99397
• Physicians Plus 99408 99409 covered
• Time and discussion need to be documented

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Commercial Payer Information

• United Healthcare 99408 99409 covered
• Processing will determine if they fall under
  behavioral or medical benefit
• Untiy 99408 99409 covered
• Behavioral health benefit
• WEA 99408 99409 covered
• WPS 99408 99409 are pended and sent to medical
  management for review of medical necessity

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Commercial Payer Information

• Cigna 99408 99409 covered
• The screening instrument used and the nature of
  the intervention activity should be documented in
  the medical record. The work effort for the
  codes is separate and distinct from all other EM
  services performed in the same session. If the
  screening shows no intervention is required, the
  screening should be included in an EM or
  preventive medicine service.

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Example

• Still must check contracts
• Patient has EM visit with physician. Health
  Educator see patients for SBI on the same day
  during same encounter. Both the EM and SBIRT
  code are billed under the NPI of the physician
• Documentation MUST be clear that SBIRT was
  provided by ancillary staff
• Employment requirement
• On- site supervision required

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Contracting

• Demonstrate through data cost effectiveness and
  measurable quality
• How do health educators fit into the continuum of
  care, create value
• Use information systems to identify costs,
  patient outcomes and satisfaction levels,
  improved quality and value to the payer
• Negotiate for credentialing health educators

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Summary

• Medicaid changes coming in 2010
• Commercial payers
• Waiting for answers
• Still work to do through contracting
• Start billing and getting reimbursed for SBIRT
  services

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Questions/Comments/DiscussionThank
Youpenny.osmon_at_wismed.org608-442-3781