Screening, Brief Intervention,
Treatment and Recover Support:
Getting Paid
Eric Goplerud, Ph.D.
The George Washington University
Medical Center
Why won’t health care providers conduct routine screenings, brief
counseling and treatment for substance use problems?
2
Obstacles to SBIRT

No time.

What’s the point?

Don’t know how.

Can’t afford it.
3
Ensuring Solutions to
Alcohol Problems
4
Ensuring Solutions to
Alcohol Problems
What Does SBIRT Cost?
 It

depends on how you do it.
Screening
Bioassay
 Online
 Paper and pencil as HRA or in a health-related location
or event
 Automated telephone service
 PDA linked to electronic medical record
 Pop-up on electronic medical record
 Interview

5
Ensuring Solutions to
Alcohol Problems
What Does SBIrt Cost?
 It

depends on how you do it.
Brief Intervention and Brief Treatment
Length of time
 Type of provider
 Setting
 Follow-up method


6
Specialty treatment
Ensuring Solutions to
Alcohol Problems
SBIRT Cost Estimate
http://gunston.doit.gmu.edu/healthscience/730/SBIRT/
Screening
• Low cost = $2.50 per screen
No lab, 5 minute screening by health educator
• High cost = $38.00 per screen
Lab plus 10 minute screening by mid-level professional
7
Ensuring Solutions to
Alcohol Problems
SBI Cost Estimate
http://gunston.doit.gmu.edu/healthscience/730/SBIRT/
Brief Intervention
• Low cost = $10.00 per intervention
 10 minute intervention by health educator plus follow-up call
• High cost = $112.50 per intervention
 30 minute intervention by mid-level professional plus follow-up
visit or call
8
Ensuring Solutions to
Alcohol Problems
Conditions Affecting Hit
Rate
Screening factors
 Setting
& patient population
 Instrument used and threshold for positive
results
Brief Intervention & Treatment Factors
 Setting
& patient population
 Type of model
 Whether routine, targeted or opportunistic
9
Ensuring Solutions to
Alcohol Problems
Likelihood of Positive
Screen, BI and Treatment
50%
40%
30%
20%
10%
0%
Positive
Screens
BI Needed
Ambulatory Medical
Hospital Emergency Dept.
Mental Health Ambulatory
TX Needed
Inpatient Medical
Trauma Center
Inpatient Psychiatric
Ensuring Solutions to Alcohol Problems
10
3%
5%
(6.25 million)
Harmful Use
1%
(1.25 million)
(3.75 million)
Dependence
Chronic
Dependence
Daily or near-daily
heavy drinking.
Almost-daily drinking.
Spectrum of Alcohol Problems
Exceed daily
limits.
Related
problems.
70%
(87.5 million)
No Problem
Related problems.
Related problems.
Never exceed daily limits.
Withdrawal
Withdrawal
Chronic or relapsing.
21% 5%
(26.25 million)
At Risk
Exceed daily
limits.
Harmful
Use
Willenbring, 2007
Center for Integrated Behavioral Health Policy
High Risk and Hazardous Alcohol Use

Targeting the 21% who drink in ways that place
themselves at risk for health problems and injury
Getting Paid for SBIRT

HCPCS

New codes approved by CMS
H0049 Screening
 H0050 Brief Intervention



In effect as of January 1, 2007
No state Medicaid agencies currently pay on these
codes

13
Close in some states – AZ, AK, WA
Ensuring Solutions to
Alcohol Problems
What did we learn?

14
Without CMS leadership
Ensuring Solutions to
Alcohol Problems
Getting Paid for SBIRT:
The Big Deal
15
Ensuring Solutions to
Alcohol Problems
CPT – Common Procedure
Terminology


New codes approved by AMA
Active since January 2009
 99408

Alcohol and/or substance use structured screening
(eg, AUDIT, DAST), and brief intervention (SBI)
services; 15 to 30 minutes
 99409


16
greater than 30 minutes
Diagnosis will be dependent on payer (V82.9)
Ensuring Solutions to
Alcohol Problems
Payment

CMS Schedule


Published in November 2008
RUC recommended values
99408 ~$24
 99409 ~$48





17
Can be billed as a separate or added service
CPT codes adopted by most health plans
(86% commercial insurers) and 17 State
Medicaid
Aetna, CIGNA, Anthem Blue Cross and Blue Shield,
HealthPlus, HealthPartners, Office of Personnel Management
Ensuring Solutions to
Alcohol Problems
(Federal Employees)
Reimburses, or will reimburse on SBI Codes
99408/99409
Aetna California PPO
310
Anthem California National PPO
152
BC of California HMO
0
Health Net of California HMO
0
Health Net of California PPO
26
Kaiser Northern California HMO 58,739
Kaiser Southern California HMO 48,000
UnitedHealthcare of California PPO
18
5
Reimbursement for SBIRT
• Resource Based Relative Value Scale
(RBRVS)
– Relative Value Units (RVU)
• Used by Medicare and HMO’s to establish
rates
• Medicaid has fee schedule amounts based
on rendering provider
What gets paid, gets done.
RVUs
99203
Office/outpatient visit, new, 30 minutes
2.54
99283
Emergency dept visit, moderate complexity
1.68
99443
98968
Physician or healthcare prof. follow-up phone call
21-30 min (Not Medicare reimb.)
0.98
99420
Administration, interpretation of health risk
assessment instrument (not Medicare reimb.)
0.23
99402
Preventive medicine, individual, 30 min (not
Medicare reimb.)
1.48
38100
Removal of spleen, total
28.23
61514
Removal of brain abscess
48.04
99409
SBI 30 minutes or more
1.67
2008 RVUs for SBI and comparable clinical
procedures
RVUs
90804
Psychotherapy, office, 20-30 min
1.80
90816
Psychotherapy, hospital, 20-30 min
1.60
99202
Office/outpatient visit, new 20 min
1.77
99408
SBI 15 to 30 min
0.85
99203
Office/outpatient visit, new 30 min
2.54
99385
Prevention visit, new, age 18-39
2.66
99409
SBI over 30 min
1.67
Reimbursement for SBI
Payer
Commercial
Insurance and
Medicaid
Code
Description
Fee Schedule
CPT
99408
Alcohol and/or substance abuse
structured screening and brief
intervention services; 15 to 30
minutes
$33.41
CPT
99409
Alcohol and/or substance abuse
structured screening and brief
intervention services; greater
than 30 minutes
$65.51
G0396
Alcohol and/or substance abuse
structured screening and brief
intervention services; 15 to 30
minutes
$29.42
G0397
Alcohol and/or substance abuse
structured screening and brief
intervention services; greater
than 30 minutes
$57.69
Medicare
Explanation from the AMA
“A screening & brief intervention (SBI)
describes a different type of patientphysician interaction. It requires a
significant amount of time and additional
acquired skills to deliver beyond that
required for provision of general advice.
SBI techniques are discrete, clearly
distinguishable clinical procedures that are
effective in identifying problematic alcohol
or substance use.”
AMA CPT Symposium, November 2007
Explanation from the AMA
• Recognizes the importance of screening
and intervening for the person who is not
necessarily an identified substance abuser
(e.g. in the ED for a trauma)
• The screening uses structured validated
assessments, although there is no
maintained list
• The screening and intervention must be a
minimum of 15 minutes in duration
AMA CPT Symposium, November 2007
Explanation from the AMA
• Components include:
– Use of a standardized screening questionnaire.
– Feedback concerning screening results.
– Discussion of negative consequences that have
occurred; and the overall severity of the
problem.
– Motivating the patient toward behavioral change.
– Joint decision-making process regarding alcohol
and/or drug use.
– Plans for follow up are discussed and agree to.
AMA CPT Symposium, November 2007
Clinical Definitions and Billing
• Brief screening is not a separately billable
service
– Full Screen or Brief Assessments are billable
• Intervention can include:
– Brief intervention
– Brief treatment
– Referral
– Follow-up
Medicare’s Equivalent
• Medicare codes for SBI
– G0396
• Alcohol and/or substance abuse (other than
tobacco) abuse structured assessment (e.g.
AUDIT, DAST) and brief intervention, 15 to 30
minutes
– G0397
• Greater than 30 minutes
Why are the Medicare Codes
Different?
• CPT codes suggest the potential to include
“screening services”.
• Medicare does not typically cover screening
services in the absence of signs/symptoms or
illness/injury.
– Would not meet the statutory requirements for
coverage of a screening service outlined in
§1862(a)(1)(A) of the Social Security Act.
Source: CMS Transmittal 1423
Why are the Medicare
Codes Different?
• Medicare caveat
– “when performed in the context of the
diagnosis or treatment of illness or injury.”
– Medicare will make payment to physicians
only when appropriate and reasonably
necessary (i.e., when the service is provided
to evaluate patients with signs/symptoms of
illness or injury)
• Diagnosis should not be a screening diagnosis
Source: CMS Transmittal 1423
Time-Based Codes
• Both the CPT & Medicare codes are timebased
– Carefully document the time spent in
counseling and interviewing to support the
code billed
– If billing an office visit (Evaluation and
Management) E&M service, the SBI must be
separate and identifiable.
Documentation for Coding
Based on Time
“In the case where counseling and/or coordination of care
dominates (more than 50%) of the physician/patient
and/or family encounter (face-to-face time in the office or
other or outpatient setting, floor/unit time in the hospital or
nursing facility), time is considered the
key or controlling factor to qualify for a particular level of
E/M services.”
DG: If the physician elects to report the level of service
based on counseling and/or coordination of care, the total
length of time of the encounter (face-to-face or floor time,
as appropriate) should be documented and the
record should describe the counseling and/or activities to
coordinate care
Source: CMS 1997 E&M Documentation Guidelines
What about Health Educators?
• Health educators are considered
ancillary/auxiliary providers
– Not credentialed with private or federal payers
– Typically able to operate under supervision of
a credentialed provider (MD, DO, PA, NP)
• Direct Supervision
• Adhere to plan of care
• Co-signature requirement on documentation
– Codes reported will depend on payer
Health Educator is the Provider
• Medicaid
– Billing under E/M codes as ancillary
provider type using CPT 99211 or 99212
• Medicare
– Bill “Incident-to” using CPT 99211
• Commercial Payers
– SBIRT codes “under supervision”
• Is it mental health benefit or medical benefit?
Ancillary Provider Guidelines
• Medicaid rules include:
– Direct, immediate, on-site supervision of a
physician
– Services are pursuant to the plan of care
– The supervising physician has not also
provided Medicaid reimbursable service during
the same office or outpatient E&M
• Can’t bill in addition to or combine the services
• Health educators meet the definition of
ancillary provider
Ancillary Provider Guidelines
• Claims are submitted to Medicaid using
the supervising physician’s NPI
– Using the lowest appropriate level office visit
CPT code for the services performed, typically
a 99211 or 99212
– Supervising physician is rendering provider
99211 and 99212
99211: “Office or other outpatient visit for
the evaluation and management of an
established patient, that may not require
the presence of a physician. Usually, the
presenting problem(s) are minimal.
Typically, 5 minutes are spent performing
or supervising these services.”
Source: CPT Professional Edition ,2009
99211 and 99212
99212: “Office or other outpatient visit for the
evaluation and management of an established
patient, which requires at least 2 of these 3 key
components:
• A problem focused history
• A problem focused exam
• Straightforward medical decision making
Usually, the presenting problem(s) are self limited
or minor. Physicians typically spend 10 minutes
face to face with the patient and/or family.
Source: CPT Professional Edition ,2009
The Setting Matters
• Site of service for SBIRT may include:
– Ambulatory outpatient
• Office, hospital outpatient
– Place of service 11, 22
– Emergency department
• Place of service 23
– Hospital Inpatient
• Place of service 21
– FQHC/Public Health Clinic
• Place of service 50/71
SBIRT In the Office
• Free standing office
– Place of Service 11
• Provided by the health educator
– Know your payers and contracts:
• Commercial 99408 & 99409
– Under supervision
• Medicare (Incident to)
– Established E&M service (CPT 99211)
• Medicaid (Ancillary Service)
– CPT 99211 or 99212
» (documentation requirements or time)
SBIRT in a Provider Based Clinic
or Outpatient Hospital
• Place of service 22
• Billing codes depend on payer and provider of
service
• Depends on who employs the health educator
or physician
SBIRT in a Provider Based Clinic
or Outpatient Hospital
• May be applicable facility code (technical)
billed to in addition to professional code when
provider based
– Can’t bill “incident-to”, supervision requirements
are different
– Revenue Code 942 on UB-04 and SBIRT Code
Medicare Supervision Requirements
Supervision: The policy for general supervision in the
outpatient hospital setting is different from the direct
supervision requirements for the office/clinic setting.
Supervision requirements for outpatient hospital settings are
the same as the definition at 42CFR 410.27 for services at
provider based facilities. The physician/NPP supervision
requirement in the outpatient hospital setting is generally
assumed to be met where the services are performed on
hospital premises. However, to assure the assumption is
appropriate, there must be a physician/NPP, who is a
member of the hospital staff, on the hospital premises at the
time of the service and immediately available to render
assistance and direction throughout the performance of the
procedure. Documentation must indicate that this requirement
is met.
Source: Medicare Benefit Policy Manual (MBPM) Chapter 15 section 60
“Immediately Available” Defined
"Immediately available" in the outpatient hospital setting
may be interpreted as equivalent to the availability of a
physician/NPP designated to manage arrests in the
hospital. The supervisor need not be in the same
department as the ordering physician/NPP or in the same
department in which the services are furnished. The
supervisor may be identified in the medical record or
hospital policy by job description, rather than by name.
For example, there may be a hospital medical officer, or
the physician/NPP responsible for the cardiac arrest
team. As long as the supervisor will be in the hospital,
immediately available if needed, and can be identified by
the hospital for purposes of Medicare claim review.
Source: Social Security Act (SSA) Section 1861(s)(2)(K)(i)
Who Employs the Billing Provider
Makes a Difference
• Could be:
– Independent billing physician
– Hospital employee
– Employee under contract
• CPT codes for E&M services will be
established or new office/outpatient codes
– 99201-99205 (new)
– 99211-99215 (established)
• Health educators are limited by payer
SBIRT in the Emergency
Department
• Place of service 23
• Will be a facility charge as well
– If SBIRT service is provided by salaried
employee of the hospital, it is included in the
facility charge and no professional service is
billed
• Billing codes depend on payer and
provider of service
SBIRT in the Inpatient Setting
• Place of service 21
• Billing codes depend on payer and
provider of service
• Could include patients in med/surg, ICU,
psych, or other inpatient area.
SBIRT in the FQHC
• Place of Service 50
• Same coding guidelines as freestanding
clinic
– Reimbursement is different
Smoking and
Tobacco Cessation
CPT Codes
• 99406: Smoking and tobacco use
cessation counseling visit; intermediate,
greater than 3 minutes up to 10 minutes
• 99407: intensive, greater than 10 minutes
Rules in General
• Face to face
• Time and counseling must be documented
– And subtracted from E&M time
• Can be used multiple times
Example: If the E&M visit took 25 minutes and
the smoking cessation was provided face to
face for 15 minutes, the E&M if based on time,
would be 10 minutes. (99212)
– Modifier 25 appended to the E&M
Smoking Cessation
~Commercial Payer~
• Provided by health educator
– Ancillary service under on-site supervision
– E&M on same day by physician
• Documentation must indicate ancillary service by
who, and include the counseling elements and time
Smoking Cessation
~Medicare~
• CPT 99406 & 99407
– Same CPT definitions
– Deductible and co-insurance apply
– Can bill E&M on the same day with modifier 25
– Limited to 8 smoking cessation attempts in a
12 month period
Diagnosis Requirement
• Diagnosis code must reflect the condition
that is adversely affected by tobacco use,
or
• The condition the patient is being treated
for with a therapeutic agent whose
metabolism or dosing is affected by
tobacco use
Medicare Definitions
• Cessation counseling attempt: occurs
when a qualified practitioner determines
that a beneficiary meets the eligibility
requirements and initiates treatment with a
cessation counseling attempt.
• 1 Counseling attempt = up to 4 sessions
– 2 allowed per 12 months
Medicare Definitions
• Cessation counseling session: Face to
face patient contact of either the
intermediate (3-10 minutes) or the
intensive (greater than 10 minutes) type
performed either by or “incident to” the
services of a qualified practitioner for the
purposes of counseling the beneficiary to
quit smoking or tobacco use
Reimbursement
• Commercial Average
– 99406: $13
– 99407: $30
• Medicare:
– 99406 Non-facility $12.46 Facility $ 11.13
– 99407 Non-facility $24.16 Facility $23.16
• Medicaid
– Provided as E/M as ancillary service
• 99211 or 99212
Billing with Evaluation
and Management
(E&M) Codes
SBI Reimbursement Strategies
Providers can be
reimbursed for SBI
– even without
specific codes.
http://www.ensuringsolutions.org/resources/
resources_show.htm?doc_id=385233&cat_id=964
58
Evaluation & Management (E&M)
Elements
• History, Exam and Medical Decision Making
– Need 3 of 3 for new patients (99201 – 99205)
– Need 2 of 3 for established patients
(99211 -99215)
Evaluation & Management (E&M)
Elements
• Or may report based on time
– Greater than 50% of visit must be counseling
and/or coordination of care
• Documentation is key!
– Both time and “what” the counseling entailed
– Example: I spent 15 minutes with the patient today and
all 15 minutes were used counseling the patient on
potential risk behaviors.
» The note should include the nature of the counseling
Billing with E/M Codes
• Physicians are typically defined by
specialty and group
– All physicians within the same specialty, same
group = 1 physician for billing purposes
Example: Two primary care physicians provide
two E&M services on the same day to the
same patient, only one E&M can be billed,
combining documentation
Multiple Services on the Same Day
• Physicians can bill for an E&M and the
provision of SBIRT services on the same
day when personally performing the
services
– Example: 99214 (E&M, established patient) &
99408 (SBIRT for commercial payer)
– Example: 99203 (E&M, new patient) & G0396
(SBIRT for Medicare)
Example
50-year-old male seen for unscheduled visit for cold
symptoms and wheezing. History of acid reflux,
headaches, mild hypertension, alcoholism in three
first-degree relatives. The patient recently lost his job,
and uses alcohol socially several time per week.
DX: URI, prescribed an inhaled beta-2 agonist. The
physician assessed risk of alcohol use disorder with a
standard 10-item AUDIT questionnaire. Patient
provided feedback about drinking and medical
concern, generated option to reduce drinking,
developed plan and commitment to change. Greater
than 30 minutes of SBI.
E&M and 99409 may be billed
Example
Patient presents for an annual preventive exam.
During the exam, physician performs a CAGE
survey to assess alcohol abuse as protocol.
Patient is referred to an alcohol program. Twenty
minutes is spent convincing the patient there is a
drinking problem.
The service described does not sound like
specific SBI interventions, but may be reported
with an E&M.
AMA CPT Symposium, November 2007
Multiple Services on the Same Day
• If a physician and a health educator provide
multiple services to the same patient on the
same day, only the physician (credentialed
provider) may bill for services.
– E&M would be billed based on the 3 elements or
on time and counseling/coordination of care
– Only historical elements from the health educator
could be included in the level of service
• Past family, social, medical history, and
• Review of systems (For Medicare)
Site of Service Matters
SBIRT in the ED
• CPT codes are:
– 99281-99285
– SBIRT Can be billed in addition when
performed by a credentialed provider
• 99408, 99409, G0396, G0397
• Would be rare for separate payment to health
educator
Ensuring Solutions to Alcohol
Problems
68
SBIRT in the FQHC
• Same billing requirements as the office
– Reimbursement will be “encounter rate” and is all
inclusive
– Encounters with more than one health professional
and multiple encounters with the same health
professionals which take place on the same day and at
a single location constitute a single visit, except when
one of the following conditions exist:
• (a) after the first encounter, the patient suffers illness or injury
requiring additional diagnosis or treatment;
• (b) the patient has a medical visit and a clinical psychologist
or clinical social worker visit.
Source: IOM 100-09, Chapter 1, Section 20.1
Ensuring Solutions to Alcohol
Problems
70
SBIRT in the Hospital
• Outpatient
– Both facility and professional fee
• E/M codes 99201-99215 (reported by both), and/or
• SBIRT codes
• If provided by health educator, payer and
employment drives coding and reimbursement
SBIRT in the Hospital
• Inpatient
– Facility fee = DRG
• No separate payment, “bundled in”
– Professional fee
• E/M (99221-99223 or 99231-99233) and SBIRT
codes
– No separate payment for health educator
Ensuring Solutions to Alcohol
Problems
73
What is Incident-to??
What is Incident-to?
It is a Medicare guideline ONLY!
“Incident to a physician’s professional services
means that the services or supplies are
furnished as an integral, although incidental,
part of the physician’s personal professional
services in the course of diagnosis or
treatment of an injury or illness”
Five Key Concepts of
“Incident-to”
1.
2.
3.
4.
Professional service
Location
Employment relationship
Incidental but physician/NPP performs initial
service
5. Supervision, direct
Must meet all criteria for “incident-to”
Medicare’s Personal
Performance Policy
• General rule
– Physicians (and nonphysician practitioners
NPP’s,) are only paid
for what they
personally perform
and document
An Exception to Medicare’s
General Rule
• Incident to services are performed by
personnel who are NOT physicians, but
are paid for performing physicians
services
Who can provide
Incident-to services??
Definition of
“Auxiliary Personnel”
• Auxiliary Personnel – “any individual”
who is acting under the supervision of a
physician…..
Auxiliary Personnel
• “Any individual” – CMS deliberately chose this
term when defining “auxiliary personnel”
– “So that the physician (or other practitioner), under his
or her discretion and license, may use the service of
anyone ranging from another physician to a medical
assistant.”
– “...impossible to exhaustively list all incident-to
services and those specific auxiliary personnel who
may perform each service.”
Federal Register/Vol. 66, No. 212/ Thursday November 1, 2001, pgs 55267 – 55268
Auxiliary Personnel
vs. Practitioners
• Auxiliary Staff
– Such as RNs, technicians, health educators and other aids
(not a complete list)
– May meet criteria for 99211
• Practitioners/NPP
– PA, NP, certified nurse midwife, clinical psychologists,
clinical social workers, certified registered nurse
anesthetists and clinical nurse specialists
– Not restricted to level of E/M service or appropriate
specialty code (must be within scope of practice)
***Cautionary Note***
• Each occasion of service by auxiliary staff
does not necessarily warrant the billing of
a personal, professional service by the
physician.
Where can you
apply Incident-to?
2. Location, Location, Location
• Physician’s office or clinic ONLY
• Applies to outpatient clinic setting but not
outpatient hospital clinic setting
• No incident-to billing in an “institutional
setting,” such as a hospital or a Skilled
Nursing Facility (SNF)
Office within an Institution
• Must be confined to a separately identified part
of the facility used solely as the physician’s
office and
– Cannot be construed to extend throughout the entire
institution
• Services performed outside the “office” area
– Subject to the coverage rules outside the office
setting
3. Employment Requirements
• May be a part-time, full-time or leased
employee or independent contractor
– Both the supervising physician and the
auxiliary personnel furnishing the service must
meet the employment requirements
– Reassignment of benefits must be executed
4. Initial Service Requirement
To bill incident-to, ‘there must have been a
direct, personal, professional service furnished
by a the physician to initiate the course of
treatment of which the service being performed
by the non-physician practitioner is an incidental
part, and there must be subsequent services by
the physician of a frequency that reflects his/her
continuing active participation in and
management of the course of treatment.’
Established Patient
“An established patient is one who has
received professional services from the
physician or another physician of the same
specialty who belongs to the same group
practice, within the past three years.”
(CPT, 2009)
Established Plan of Care
• The personnel performing the incident-to
service should:
– Document the ‘link’ between their face-to-face
service and the preceding physician service to
which their service in incidental.
– Reference by date and location the precedent
providers’ service that supports the active
involvement of the physician.
– Legible record both their identity and credentials
5. Direct Supervision
“Direct supervision in the office setting
does not mean that the physician must be
present in the same room with his/her
aide. However, the physician must be
present in the office suite and immediately
available to provide assistance and
direction throughout the time the aide is
performing the services.”
Direct Supervision – What it is
• Physician readily available in the office
suite seeing patients in an adjacent exam
room.
• There must be a specific physician
responsible for the supervision of the billed
service.
Direct Supervision –
What it is not
• Physician doing rounds at the hospital and
the auxiliary staff performing the service in
the office.
• Physician having lunch downtown and is
available by phone.
Supervising Physician
• The physician who performed the initial
assessment and initiated the course of
treatment does not need to be the
physician supervising the incident-to
service.
CPT code 99211 &
How to Bill Incident-to
(Medicare guideline)
CPT code 99211
“Office or other outpatient visit for the
evaluation and management of an
established patient, that may not require
the presence of a physician. Usually, the
presenting problem(s) are minimal.
Typically, 5 minutes are spent performing
or supervising these services.” (CPT, 2009)
Criteria for billing 99211 as
“incident-to”
• Must be an established patient
• There must be an established plan of care.
• There must be an E/M service provided by
an employee of the physician.
• Must be provided in the office.
• There must be direct physician
supervision.
Auxiliary Personnel
• Can only bill lowest level of E/M service,
code 99211.
• Medicare will pay the claim at 100% of the
physician fee schedule, even though the
services were furnished by the auxiliary
personnel. (health educator)
Non-Physician Personnel (NPP)
•
•
•
•
•
•
•
Nurse Practitioner
Nurse Midwife
Clinical Nurse Specialist
Physician Assistant
Clinical Psychologist
Clinical Social Workers
Physical/Occupational Therapists
Non-Physician Personnel
• NPP can bill E/M levels 99211-99215.
• Medicare will pay the claim at 100% of the
physician fee schedule, even though the
services were furnished by the NPP.
• NPP’s can also establish the plan of care.
– Health educators could bill 99211 “incident to”
a initial service provided by a NPP.
Performance of E/M Service
• No specific criteria in CPT for a 99211 (eg.
level of history, exam or medical decision
making).
• Face-to-face encounter with the auxiliary
personnel and the patient consisting of
both ‘evaluation and management’.
Documentation
• The medical record must be adequately
documented to reflect the reason for the
patient’s visit and any treatment rendered.
• The medical record must include elements
of history obtained, examination performed
and/or clinical decision making.
• The medical record must support
physician supervision.
Summary
• Check for established patient and plan of
care.
• Watch the location.
• Health educator must be employed by
billing physician or NPP.
• Heed the supervision rules.
• Document, document, document.
SBI Reimbursement
Strategies
Providers can be
reimbursed for SBI –
even without specific
codes.
http://www.ensuringsolutions.org/resources/
resources_show.htm?doc_id=385233&cat_id=964
104
Extended Continuum
Heavy drinking
only
Harmful
drinking
Dependence
Chronic
Increased quantity, frequency & consequencesof alcohol use
Facilitated
self change
Brief
motivational
counseling
Disease
Specialized Management
Medical
remissionmanagement + oriented
pharmacotx
treatment
or CBI
The extended continuum
Moderate
Widespread availability
• Internet
Chronic
• Toll-free telephones (QUIT
lines)
• EAP & occupational health
• Schools & workplaces Disease
Specialized Management
•Medical
Primary care, hospital
remissionemergency
departments
management +
oriented
• Criminal justice
system
pharmacotx
treatment
Severe
Facilitated
self change
Brief
motivational
counseling
or CBI
The extended continuum
Moderate
Severe
Facilitated
self change
Brief
motivational
counseling
Next step
• Primary care
• General MH care
• Bulk of people needing
Chronic
treatment
are here
Disease
Specialized Management
Medical
remissionmanagement + oriented
pharmacotx
treatment
or CBI
The extended continuum
Moderate
Severe
SUD Specialty sector
Chronic
• Fully integrated with medical
and psychiatric care systems
• Able to manage severe
Disease
co-morbidities
Specialized Management
• Disease management forMedical
remissionchronic orBrief
relapsing disorders
management + oriented
Facilitated
self change
motivational
counseling
pharmacotx
or CBI
treatment
Center for Integrated Behavioral Health Policy
Department of Health Policy, The George Washington University Medical Center
Eric Goplerud, Ph.D.
Director
2021 K St. NW, Suite 800
Washington, DC
goplerud@gwu.edu
integratedbehavioralhealth .org