Primary Care Coding Alert

Answer: When 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) is the primary service, or column 1 code, with 99408 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes), the NCCI procedure-to-procedure (PTP) edit for this pair has an indicator of 0, meaning you cannot bill the codes together.

The NCCI edit is inconsistent with guidelines preceding the “Behavior Change Interventions, Individual” family of codes in CPT^®, which say:

“Behavior change services may be reported when performed as part of the treatment of condition(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness. Any E/M services reported on the same day must be distinct and reported with modifier 25 (emphasis added), and time spent providing these services may not be used as a basis for the E/M code selection.”

This means you’ll have to show that the E/M service represented by 99213 was distinct form 99408 for payers that don’t adhere to the NCCI edits.

Also, don’t forget the issue of time. CPT^® tells you that you cannot report services of less than 15 minutes with 99408. And for services greater than 30 minutes, you’ll use 99409. But, most importantly per the guidelines, you must make sure you separate out the 99408/99409 time from the E/M — in other words, you can’t double dip.

One other issue: Medicare has assigned code 99408 a status of “N” in its physician fee schedule, essentially meaning that Medicare does not cover the code. Medicare and payers following Medicare rules instead recognize HCPCS codes G0396 (Alcohol and/or substance (other than tobacco) misuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes) or G0397 (… greater than 30 minutes) rather than 99408/99409. That’s a payer-specific question you’ll need to ask. The good news is that while NCCI has edits making G0396 and G0397 column 2 codes to 99213 as a column 1 code, those edits do permit a modifier to override them.