Psychiatry Coding & Reimbursement Alert

Question: Our psychiatrist recently provided behavioral counseling for alcohol misuse to a 69-year-old Medicare patient. The duration of the session lasted 15 minutes. We reported the counseling session that our psychiatrist provided with the HCPCS code G0443. But the claim was denied. Can you tell us why the claim was rejected, as the counseling was provided to a Medicare patient and the service is covered presently under Medicare? He has not been previously counseled for alcohol misuse, and he has no other medical complications of note.

Michigan Subscriber

Answer: The most likely explanation is that the claim was denied because Medicare does not cover this service when provided by a psychiatrist. Section 180.3 of Chapter 18 of the Medicare Claims Processing Manual states:

For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when services are submitted by the following provider specialties found on the provider's enrollment record:

01 - General Practice

08 - Family Practice

11 - Internal Medicine

16 - Obstetrics/Gynecology

37 - Pediatric Medicine

38 - Geriatric Medicine

42 " Certified Nurse-Midwife

50 - Nurse Practitioner

89 - Certified Clinical Nurse Specialist

97 - Physician Assistant

Any claims that are not submitted from one of the provider specialty types noted above will be denied.

Since your physician is a psychiatrist and not among the specialties listed above, Medicare denied the claim. You can confirm this is the reason for denial by looking for one of the following codes on the Medicare Summary Notice or Remittance Advice:

• Medicare Summary Notice (MSN) 21.18 -- This item or service is not covered when performed or ordered by this provider.
• Claim Adjustment Reason Code (CARC) 185 -- The rendering provider is not eligible to perform the service billed. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
• Remittance Advice Remark Code (RARC) N95 -- This provider type/provider specialty may not bill this service.

In order to collect from the beneficiary for this service, you will need to have the patient sign an Advance Beneficiary Notice (ABN) in advance of providing the service and submit your claim with modifier GA (Waiver of liability statement issued as required by payer policy, individual case) appended to the code G0443 (Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes) indicating that a signed ABN is on file.

For more details check out the CMS website at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf