ED Coding and Reimbursement Alert

Use of cessation counseling codes 99406-99409 is rising and payers are starting to reimburse for them, experts say. Get on board with others reporting these codes to add between $11 and $32 for each encounter that meets the guidelines for tobacco or drug/alcohol abuse counseling.

To report a behavior change intervention code, there must be a -face-to-face interaction by a physician or other qualified healthcare professional, and involve specific validated interventions,- explains Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

These interventions typically include: 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.

You might want to use a template to document the visit and record the interventions, Edelberg says.

Example: If you wanted to formulate a counseling template for smoking cessation, Michael Granovsky,MD, CPC, FACEP, recommends including:

- the problem or diagnosis related to smoking/tobacco abuse

- any medications/drugs the patient takes that are adversely affected by tobacco use

- an outline detailing the discussion with the patient (including advice regarding how to quit, how to manage side effects, referral to a consultant MD for long-term counseling and monitoring, etc.)

- a record of time spent with the patient exclusive to counseling.

For smoking cessation counseling, many EDs base their template on the Fagerstrom Test for Nicotine Dependence, a six-question test designed to assess the patient's nicotine dependency on a scale of 1 (very low) to 10 (very high).

Use of a test like this will strengthen your claims for 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (- intensive, greater than 10 minutes). Find it online at: http://my-healths.blogspot.com/2008/06/fagerstrm-test-for-nicotine-dependence.html.

For patients who might be dependent on drugs, the Drug Abuse Screening Test (DAST) is a reliable resource(www.drtepp.com/pdf/substance_abuse.pdf). The CAGE questionnaire is a good assessment tool for patients that are potentially abusing alcohol (www.counsellingresource.com/quizzes/alcohol-cage/index.html).

Use of questionnaires such as these will strengthen your claims for 99408 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT,DAST], and brief intervention [SBI] services; 15 to 30 minutes) and 99409 (- greater than 30 minutes).

Best bet: Your ED should check out these online resources and then decide what types of assessments to use for patients. These questionnaires are a good starting point for your own templates, but might not contain all the information your ED needs to include for a rock-solid counseling claim.

When you use the 99406-99409 codes, it will usually be in addition to an E/M visit, says Granovsky, president of Medical Reimbursement Systems Inc. (MRSI), an ED billing company in Woburn, Mass.

-The ED physician would typically use a well accepted and validated questionnaire to assess and screen for smoking, alcohol, or drug problems,- explains Granovsky. If the patient has a -positive- screening questionnaire, the physician would follow up with specific targeted counseling related to decreasing the use of or dependence on the substance, he says.

Example: A 52-year-old male with essential hypertension and type II diabetes presents with suspected bronchitis and elevated blood pressure. The physician notes that the patient smokes two packs a day. Following a detailed history and physical exam, the patient receives two nebulizer treatments. The ED physician confirms obstructive chronic bronchitis with exacerbation, writes prescriptions for antibiotics and inhalers, and then administers a Fagerstrom test to assess the patient's dependence on nicotine.

The patient appears to have moderate-to-severe dependence on nicotine, so the physician discusses pharmacologic interventions (Nicorette gum, prescription patch) and the availability of community support groups.The counseling lasts six minutes.

In this example, Granovsky says you can code separately for the tobacco counseling. On the claim, report the following:

- 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) for the E/M

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M was separate from the other services the physician provided

- 491.21 (Obstructive chronic bronchitis with [acute] exacerbation) appended to 99284 to represent the patient's bronchitis

- 250.00 (Diabetes mellitus without mention of complication: type II or unspecified type, not stated as uncontrolled) and 401.1 (Essential hypertension; benign) appended to 99284 to represent the patient's underlying conditions

- 99406 for the smoking cessation counseling

- 491.21 and 305.1 (Tobacco dependence) appended to 99406 to represent the patient's nicotine dependence.

Carrier acceptance for these counseling codes is uneven, experts concede. Insurers that do pay them, however, offer your ED about $11 for 99406 (0.32 transitioned facility relative value units [RVUs] multiplied by Medicare conversion rate of 36.0666) and $32 for 99408 (0.88 RVUs multiplied by 36.0666).

-Medicare pays for these services if all criteria are met, and many commercial carriers will, but payment from Medicaid will vary from state-to-state-- explains Edelberg.

On counseling claims, -it is important to distinguish the time spent performing counseling as separate and distinct from other services performed at the same session,- Edelberg stresses. Be sure to record this counseling separate from the documentation for the other E/M service -to assure that both the E/M and the counseling code are paid,- she says.

Best bet: Check with your individual carriers to see if they are paying for 99406-99409. If they are, be sure to note each insurer's criteria for 99406-99409 encounters.

The more claims that carriers get with counseling codes on them, the higher the usage rate will be. This usage spike increases the chances that 99406-99409 are accepted more often -- and paid higher -- in the future.