Screening, Brief Intervention
and Referral-to-Treatment
SBIRT Billing – Getting Paid
Presented by: Penny Osmon, BA, CHC, CPC, CPC-I, PCS
Coding & Reimbursement Educator
Wisconsin Medical Society
Penny.osmon@wismed.org
Objectives
• Participants will learn how to bill for SBIRT
services when performed with other
services on the same day.
• Participants will have an understanding of
documentation requirements for
reimbursement.
• Participants will learn when to append
modifiers.
• Participants will gain knowledge of various
reimbursement models for federal and
commercial payers.
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 type
Reimbursement for SBIRT
SBIRT
Work RVU
99408 &
G0396
.65
Total
Facility
RVU
.82
Total NonFacility
RVU
.86
99409 &
G0397
1.30
1.64
1.68
99211
Medicare
.17
.24
.52
Reimbursement for SBIRT
Medicare
– G0396
• Facility $30.23
• Non-Facility $28.91
– G0397
• Facility $57.63
• Non-Facility $58.96
– 99211
• Facility $8.27
• Non-Facility $17.57
• 85% if reported by PA/NP
Medicaid
– H0002 (pregnant)
• $35.35
– H0004 (pregnant)
• $20.23
– 99212 (non-pregnant)
• No modifier $21.96
• HPSA modifier
– Under 18 $28.37
– Over 18 $26.35
• TJ modifier
– $23.65
Reimbursement for SBIRT
• Commercial Payers
– 99408: averages $33.41
– 99409: averages $65.51
– Diagnosis code for best practice:
• V82.9, Screening for unspecified condition
Some Medicaid
“Need to Knows”
Health Professional Shortage Area
(HPSA)
• Enhanced reimbursement
– Primary Care and ED
• Based on address of:
– Either the billing provider, or
– The enrolled member’s address
• Incentive is an additional 20% of the
maximum fee amount
– Requires modifier AQ
TJ Modifier
• Medicaid only
• Enhances payment for pediatric services
• Applied to CPT 99201 – 99215
– Patient under age 18
– Applies specifically for SBIRT when 99211 or
99212 is billed for services by a health
educator
Documentation Requirements
• Name of the patient
• Who provided the service
• The purpose/need for the service
– (medical necessity or reason)
• Accurate description of the service
– Legible if hand written
• Date of service and place of service
• Quantity and level of service
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
Billing with Evaluation
and Management
(E&M) Codes
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)
Multiple Services on the Same Day
– E&M would be billed based on the 3 elements or
on time and counseling/coordination of care
• Commercial payers will reimburse health educator
services on the same day under supervision
– 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
Historical Information
• For purposes of SBIRT may include:
– Historical information gathered during alcohol
and drug screening and assessment
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 times 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
Site of Service Matters
SBIRT in the ED
• CPT codes are:
– 99281-99285
– SBIRT may be billed in addition when
performed by a credentialed provider
• 99408, 99409, G0396, G0397
• Would be rare for separate payment to health
educator
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
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
when employed by facility
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
Commercial Payer Reimbursement
• The verdict is out
– Several have been asked to consider
payment when performed by a health
educator
• STAY TUNED!
Commercial Payer Information
• Anthem: 99408 & 99409 are covered
– Processed under medical benefit for
Wisconsin insured members
– No payment if billed with preventive CPT
codes 99381-99387 & 99391-99397
• Physicians Plus: 99408 & 99409 covered
– Time and discussion need to be documented
Commercial Payer Information
• United Healthcare: 99408 & 99409 covered
– Processing will determine if they fall under
behavioral or medical benefit
• Untiy: 99408 & 99409 covered
– Behavioral health benefit
• WEA: 99408 & 99409 covered
• WPS: 99408 & 99409 are pended and sent
to medical management for review of
medical necessity
Commercial Payer Information
• Cigna: 99408 & 99409 covered
– The screening instrument used and the nature
of the intervention activity should be
documented in the medical record. The work
effort for the codes is separate and distinct
from all other E&M services performed in the
same session. If the screening shows no
intervention is required, the screening should
be included in an E&M or preventive medicine
service.
Example
• Still must check contracts
Patient has E&M visit with physician.
Health Educator see patients for SBI on the
same day during same encounter. Both the
E&M and SBIRT code are billed under the
NPI of the physician
• Documentation MUST be clear that SBIRT
was provided by ancillary staff
– Employment requirement
• On- site supervision required
Contracting
• Demonstrate through data cost
effectiveness and measurable quality
– How do health educators fit into the continuum
of care, create value
• Use information systems to identify costs,
patient outcomes and satisfaction levels,
improved quality and value to the payer
• Negotiate for credentialing health educators
Summary
• Medicaid changes coming in 2010
• Commercial payers
– Waiting for answers
– Still work to do through contracting
• Start billing and getting reimbursed for
SBIRT services
Questions/Comments/Discussion
Thank You
penny.osmon@wismed.org
608-442-3781