Primary Care Coding Alert

Watch CCI when reporting other assessment or E/M codes in the same session.

When your FP screens or counsels a patient for alcohol misuse, you will need to know what codes to report for each service, the frequency at which you can report these services, and which of these codes you can and cannot report together.

Discern Between Screening and Counseling Codes

When your family physician performs screening for alcohol misuse or counseling for alcohol misuse, you’ll have to report one of the following HCPCS G codes:

• G0442 (Annual alcohol misuse screening, 15 minutes)
• G0443 (Brief face-to-face behavior counseling for alcohol misuse, 15 minutes)

Primary care providers can now collect for an annual alcohol misuse screening at no cost to the patient. If the screening turns up positive for alcohol misuse, Medicare will cover four behavioral counseling sessions each year to treat the alcohol issues. 

Background: The United States Preventive Services Task Force (USPSTF) emphasizes that evidence regarding the effectiveness of brief behavioral counseling interventions in the primary care setting remains largely restricted to persons 18 years or older who are engaging in risky or hazardous drinking. The USPSTF Recommendation Statement (2013) defines risky or hazardous drinking as drinking more than the recommended daily, weekly, or per-occasion amounts resulting in increased risk for health consequences. For example, the USPSTF statement notes that the National Institute on Alcohol Abuse and Alcoholism and the U.S. Department of Agriculture define “risky use” as:

• For women: more than 7 drinks per week, or more than 3 drinks per day; and
• For men: more than 14 drinks per week, or more than 4 drinks per day.

For more details, check the link at http://www.uspreventiveservicestaskforce.org/uspstf12/alcmisuse/alcmisusefinalrs.htm

Consider These Alcohol Screening Payment Specs

CMS covers an annual alcohol screening for all Medicare beneficiaries. Medicare beneficiaries that may be identified as having a need for behavioral counseling sessions include those who meet the following criteria:

• Patients who misuse alcohol, but "whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and
• Competent and alert at the time of counseling; and
• Counseling is furnished by qualified primary care physicians "or other primary care practitioners in a primary care setting."

Don’t Report Counseling Without Prior Screening

As per guidelines laid down by the Centers for Medicare and Medicaid Services, any counseling that is provided for alcohol misuse (G0443) will be denied if your FP does not first screen the patient for alcohol misuse. The screening prior to the counseling could have occurred any time in the past one year.

You can report G0442 and G0443 with the same date of service if your FP performs both these services on the same day. However, you cannot report multiple units of G0443 for the same date of service, and it will be paid out only for one session on one calendar date. It is also important to note that you can report screening services only once a year, and if reported within the period of one year of previous reporting, the service will be denied reimbursement.

Documentation: Ensure that the chart reflects that a qualified provider performs the screening and counseling. The screening and the counseling should be performed by the beneficiary’s primary care physician (which CMS defines as general practice, family practice, internal medicine, obstetrics/gynecology, pediatric medicine, or geriatric medicine) or by the beneficiary’s physician assistant, nurse practitioner, certified nurse midwife, or certified clinical nurse specialist.“Note that CMS also limits coverage and payment to certain sites of service,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. According to Moore and section180 of chapter 18 of the Medicare Claims Processing Manual, CMS only pays for the service if it is provided in one of the following places of service:

• Physician’s Office
• Outpatient Hospital
• Independent Clinic
• State or local public health clinic

Check CCI Before Reporting Screening Codes With Other Assessment Codes

If you are planning to report the CPT® codes for alcohol and substance abuse assessment with G0442 or G0443, you need to note that these codes face Correct Coding Initiative (CCI) edits. These edits carry the modifier indicator ‘0,’ which means that you cannot unbundle the codes under any circumstances. Note that these CPT® codes form the column 2 codes and are not separately reportable:

• 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).

Reminder: You also cannot use the HCPCS codes G0396 (Alcohol and/or substance [other than tobacco] abuse structured assessment [e.g., AUDIT, DAST], and brief intervention 15 to 30 minutes) and G0397 (...greater than 30 minutes) along with G0443 as these codes are mutually exclusive. “G0396 and G0397 are the Medicare versions of CPT® codes 99408 and 99409, above. Codes 99408 and 99409 are status “N” in the Medicare physician fee schedule, which means that they are non-covered for Medicare purposes,” Moore adds. 

Coding tip: If you are planning on reporting any health and behavioral assessment or intervention codes with G0442 or G0443, you again face edits. In such a scenario, you will only be able to report the health and behavioral assessment (96150-96151) codes or the interventional codes (96152-96154) and not G0442 or G0443. This is because the codes for health and behavior assessment and these G codes for CCI edit pairs that carry the modifier ‘0,’ which means that these codes sets are mutually exclusive and you cannot reported these codes together under any circumstances. The health and behavior assessment or intervention code is the column 1 code in each edit pair. 

Exercise Caution When Reporting Same Session E/M Service

When your FP performs alcohol abuse screening or counseling and, in the same session, performs an E/M service, you should again look at CCI as you face bundling between E/M codes and G0442 and G0443. However, the modifier indicator for these edits is ‘1,’ which means you can unbundle the codes if a suitable modifier is used.

Since G0442 and G0443 are column 2 codes in the bundling with E/M codes, you will have to append a modifier to these HCPCS codes. You will have to append a modifier such as 59 (Distinct procedural service) to G0442 or G0443 when reporting these codes with an E/M service

Example: If an established Medicare patient presents to a family physician’s office for a periodic check of his hypertension and diabetes. In reviewing the patient’s medical record, the family physician notes that the patient has not been screened for potential alcohol misuse. The family physician elects to screen the patient while he is otherwise present for the check of his hypertension and diabetes. In this scenario, the physician may report both an E/M code for the work done to check the patient’s chronic condition and G0442 for the alcohol misuse screening. To ensure both services are paid, since they were provided to the same patient on the same date, the physician appends modifier 59 to G0442.