ED Coding and Reimbursement Alert

Analyze the coding and reimbursement environment before assigning codes for smoking or substance abuse counseling.

While a busy emergency department is not the ideal venue for lengthy preventive care counseling sessions, but it can present a good opportunity to have a discussion about contributing factors that may have brought a patient to the ED for treatment. Following the advice below to ensure any behavior modification service your ED physician provides gets properly reported.

For example: Consider a patient who presents with injuries caused by driving while intoxicated or a home accident involving themselves or others that was directly related to altered status from substance abuse. Similarly, a smoker with an acute respiratory emergency may be more open to an intervention and behavior modification counseling than they would be in normal situations.

Check the Manual

The E/M section of the CPT® book contains a code set for behavior change interventions for individuals to access their readiness for change and any barriers before providing specific suggested actions and motivational counseling as well as arranging for follow-up. These time based codes (99406-99409) describe screening and brief interventions for smoking and tobacco use cessation and alcohol and/or substance abuse (other than tobacco):

99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407 ...intensive, greater than 10 minutes

99408 Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

99409 ...greater than 30 minutes

Watch for Different Codes for Medicare Patients.

Medicare has slightly different rules for these services. It has assigned status indicator A for the smoking cessation codes (99406 and 99407), and they are payable under the Medicare physician fee schedule. However, it has assigned status indicator N, meaning "not payable," to codes 99408 and 99409 and instead has its own HCPCS codes to describe theses services, so for Medicare patients you would use:

G0396 (Alcohol and/or substance [other than tobacco] abuse structured assessment [e.g., AUDIT, DAST], and brief intervention [SBI] 15-30 minutes) and

G0397 (Alcohol and/or substance [other than tobacco] abuse structured assessment [e.g., AUDIT, DAST], and brief intervention [SBI] greater than 30 minutes)

Caveat: These codes may be reported in addition to other E/M services provided on the same day, but they do require face to face counseling by the physician personally to do so. In order for the emergency physician to personally report these codes, he or she must be the one providing the direct counseling rather than by another provider such as a nurse or social worker employed by the hospital. The two services should be distinct, but can be related to the same presenting problem.

Payers expect a procedure note describing the elements listed in the CPT preamble, warns Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, Oklahoma. A note along the lines of, "Advised patient to stop smoking" or "Counseled patient on smoking cessation 3 to 5 minutes" will be insufficient documentation to support reporting these codes, advises Thomas.

Don't Forget The Structured Screening Requirement

An important aspect of the behavioral change intervention codes is the requirement for specific validated interventions and "structured screening." As you can see above, the alcohol and or substance abuse code descriptor actually contains language in the descriptor referencing screening and brief intervention. It also contains examples of structured screening tools listing the AUDIT questionnaire for alcohol and the DAST questionnaire for drug abuse.

Although there is not the same specific mention of screening tools in the smoking cessation code descriptors, there is mention of that requirement in the CPT® preamble language that applies to the whole code family, warns Thomas.

CPT states, "Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up."

In CPT Changes 2008 "Standardized evidence --"based screening tools with reliable documentation and appropriate sensitivity is required in order to separately report for these services." The AUDIT and DAST questionnaires as well as the Fagerstrom test, a structured screening tool for smoking cessation, can be found through a web search, but be mindful of copyright restrictions, Thomas adds.

Watch The Clock For The Required Time Thresholds

As mentioned, behavioral modification codes are time based and there are minimum thresholds required listed in the code descriptors. If you don't spend at least three minutes in administering the test and counseling for smoking cessation, and at least fifteen minutes for the alcohol and/or substance abuse screening and brief intervention, the services will not be separately reportable.

Consider the payments associated with each code compared with the required time spent as shown in the sidebar. Remember that these payments would be in addition to a separately reported E/M service if provided.

Check Payer Limits

Additionally, payers may have limits on how many times they will cover these services in a single year. For example, Medicare will only cover two attempts/interventions to quit smoking per year and to be eligible to receive this benefit; a beneficiary must have a condition that is adversely affected by smoking or tobacco use. If the patient has been previously screened and counseled by another provider, insurance may not pay for this service.