Screening, Brief Intervention and Referral-to-Treatment SBIRT Billing – Getting Paid

Screening, Brief Intervention and Referral-to-Treatment

SBIRT Billing – Getting Paid

Presented by: Penny OsmonCoding & Reimbursement Educator

Wisconsin Medical [email protected]

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

Reimbursement for SBIRT

SBIRT Work RVU Total Facility

RVU

Total Non-Facility

RVU99408 & G0396

.65 .82 .86

99409 & G0397

1.30 1.64 1.68

99211 .17 .24 .52

Reimbursement for SBIRTMedicare

– 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 9921299211: “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 9921299212: “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)

Example50-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

ExamplePatient 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)

Historical Information

• For purposes of SBIRT may include:– Historical information gathered during alcohol

and drug screening and assessment

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

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• 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

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, creates 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

[email protected]