ED Coding and Reimbursement Alert

Make sure you know the rules 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, it can present a good opportunity to have a discussion about contributing factors that may have brought a patient to the ED for treatment. But you'll need to master the details to properly report any behavior modification service your ED physician provides.

For example: Consider a patient who presents with injuries caused by driving while intoxicated or a home accident involving them 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 for Code Requirements

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, says Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, Oklahoma. 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 HCPCS Codes Required for Medicare Patient Screening

Medicare has slightly different rules for these services, assigning status indicator A for the smoking cessation codes (99406 and 99407), which means they are payable under the Medicare physician fee schedule. However, CMS assigns 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, 15-30 minutes) and
• G0397 (Alcohol and/or substance [other than tobacco] abuse structured assessment [e.g., AUDIT, DAST], and brief intervention, greater than 30 minutes)

Caveat: These codes are 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 provide 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, Thomas warns. A note along the lines of, "Advised patient to stop smoking" or "Counseled patient on smoking cessation for 3 to 5 minutes" will be insufficient documentation to support reporting these codes, he says.

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 no specific mention of screening tools in the smoking cessation code descriptors, there is mention of that requirement in the CPT^® code set documents that applies to the whole code family, Thomas warns.

For example:

"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.", according to the Counseling Risk Factor Reduction and Behavior Change Intervention code preamble language on page 38 of the 2017 CPT^® book.

And further clarifies that, "Standardized evidence-based screening tools with reliable documentation and appropriate sensitivity is required in order to separately report for these services.", according to page 24 of CPT^® Changes 2008^®.

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 Required Time Thresholds

Remember that the behavior modification codes are time-based codes, and there are minimum thresholds required which are 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 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 Annual Reporting 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 or 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, Thomas warns.