Category Archives: Preventative services

Substance Abuse Counseling and Intervention

Insurances, legislators, and the general public are finally understanding what many of our physicians have known for years. Without significant and timely intervention, the opiod crisis will only get worse. Right now both insurances and legislators are flailing around trying to determine what “significant and timely intervention” consists of.

 

I know that many of you are seeing a greater number of patients whose insurances are beginning to deny their pain medication refills and insist that physicians help patients taper off of opiods. I know that, for years, many of you have seen patients who need help with both real pain and an opiod addiction.

 

One of my Internal Meds is also an addiction specialist and treats patients with substance abuse issues, so we have experience with how insurances want to see the screenings and counseling for these conditions. And what they want is an absolute mess. There is no standardized service code or diagnosis, each insurance has different policies for covering these services, and even different plans within each insurance company has new and interesting hoops for you to jump through. This guide will teach you the most common combinations of codes and give you the tools and terminology to unravel the rules for plans that don’t follow these guidelines. While most of you will be primarily using these codes for your opiod patients, please do use them for patients dependent on and/or abusing other substances as well. 

 

In order to first determine if a patient is dependent on or abusing substances, they first need to be screened. I suggest that your providers incorporate substance abuse and depression screenings into their routine for physicals, and also possibly for all new patients, if you haven’t already. Please remember that your E&M code or preventative code needs a modifier 25 if you are also doing a screening or counseling in the same visit.

For screenings, you would typically use ICD10 code Z13.89 and either CPT code G0442 or H0049. 

CPT code G0442 is limited to alcohol misuse, so any additional substances that you screen for along with alcohol with not be payable separately. Most insurances don’t accept H0049.

For Blue Cross, Blue Shield, Cigna, United Healthcare Medicare Solutions, and Medicare you would bill like this:

Z13.89                                    G0442 (some insurances require either a 25 or a 59 modifier)   

For Aetna, United HealthCare, and UMR, enter the charge like this: 

Z13.89                                   H0049 (has a low reimbursement rate)

 Some patients will come into the office and let you know they are there for help with a substance abuse problem, if that is the case, then skip this step. Counselings and screenings cannot be billed on the same date because they are mutually exclusive, so if a screening comes up positive and you are going to do counseling in your office, bill the counseling codes, the reimbursement is higher. 

 

If your patient is actively abusing substances, use the ICD10 code for substance dependency (F10.10–F16.998 and F18.10-F19.988) and the service code G0396, G0397 or 99408. This also goes for people on maintenance medication that are still abusing substances.

The charge would look like this: 

F11.20                                        G0396

 

If your patient is a former drug user that is on maintenance medication and NOT currently abusing substances use ICD10 code Z71.51 and service code 99401.

The charge would look like this:

Z71.51                                       99401

 

If your patient has been using opiods with no dependency or abuse problems, but the medication still needs to be tapered off, you would use ICD10 code Z79.891 and service code 99401.

The charge would look like this: 

Z79.891                                    99401

 

There are many plans that do not fit into these neat little boxes, and these are just guidelines anyway. If your claim isn’t getting paid, the first step is to call and check benefits for your patient. Be very specific and tell them you need to check the patient’s plan for any exclusions. Give them first the ICD10 codes and service codes you are using. If there are any exclusions for those codes, check some of the other ones. Please remember, you are NOT asking if these codes are “covered”. You are asking if this plan has an exclusion for any of your codes. 

 

If there are no exclusions, your next step is to ask if the ICD10 codes you are using “match” with the service codes. For example, I billed a charge with the F11.20 and the G0396 and it was denied stating that is not a benefit of the patient’s plan. I called for benefits and I was told that the G0396 is classified as preventative for that plan and I can only use preventative ICD10 codes. At that point, I have the choice to switch the service code to 99401 or switch the ICD10 code to Z71.51. 

 

Below is a complete list of the diagnosis and service codes that you can choose from for dependency screenings and counselings. 

Diagnosis Codes

Substance dependency (F10.10–F16.998 and F18.10-F19.988) 

Drug abuse counseling and surveillance of drug abuser (Z71.51)

Long term use of opiate analgesics (Z79.891) 

Encounter for screening for other disorders (Z13.89)

 

Service codes

Alcohol and/or substance (other than tobacco) abuse structured
assessment (for example, AUDIT, DAST) and brief intervention, 15 to 30
minutes (G0396)

Alcohol and/or substance (other than tobacco) abuse structured
assessment (for example, AUDIT, DAST) and intervention greater than 30
minutes (G0397)

Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes (99401)

Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes (99402)

 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services (99408)

Annual Alcohol Misuse Screening, 15 minutes (G0442)

Alcohol and/or drug screening (H0049)

 

My last tip is to change the text that displays on your codes to have the terms “Screening for dependency” or “dependency review” or “preventive medicine counseling”. Even for patients with active drug addictions, many of them object when they receive statements with line items containing the words “substance abuse”. Even when there is no charge to them for those line items, the fact that the words “substance abuse” appears on the statement at all is enough to upset them. Since your time and your staff’s time is valuable, changing those phrases can save you a lot of aggravation. 

If you need help with any of this or if you want to arrange an in-person or webinar training for your office, call us at (909) 610-9524 or email newgenerationbilling@gmail.com. Happy billing! 

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Filed under Billing, Claims, Counseling, Medical Billing, Preventative services, Screenings

The medical assistant will see you now

A few weeks ago, a colleague gave me an interesting dilemma. One of her providers, a pediatrician, wanted to bill a 99212 with vaccines even when the patient did not see the doctor. Since the medical assistants spent some time counseling the patient, the doctor wanted to make sure the practice was paid for that time. My colleague’s question was whether or not a 99212 would be acceptable to report to the insurance company in that manner. 

Well, short story shorter, the only office visit we can bill when the provider does not see the patient is a 99211. E&M University has an excellent breakdown of the requirements for each of the codes. 

The requirements for a 99212 include a problem focused history, a problem focused exam, and straightforward medical decision making. While the MA’s can take the history, the only person medically qualified to do an exam or any medical decision making is a provider. And counseling only does not include an exam or any decision making. 

The requirements for a 99211 are incredibly broad. In fact, there are no specific requirements. Anything the patient comes in for that does not require the presence of the physician can be a 99211. Blood pressure checks, ear lavages, EKGs, vaccinations, that sort of thing. 

However, the office does deserve to be reimbursed for any time spent counseling. For pediatricians, there is a code that includes the administration of vaccines and the time spent counseling the patient/guardian. You would use code 90460 for the first vaccine and 90461 for any subsequent vaccines. These codes are also nice because they do not specify the method of administration. You can use 90460 and 90461 for vaccines administered intramuscularly, nasally, or orally.  

If the vaccine is administered with no counseling, you would use the regular 90471 and 90472 codes for your intramuscular administrations.  

As an additional consideration, the 99212 gets paid a very small amount anyway. Probably less than $35.00. AND a copay gets applied that you’ll most likely end up waiving anyway. Getting your provider paid for at least the 90460 and one 90461 will be a higher reimbursement than billing with an incorrect code. And it is my job to make sure that I get my providers the highest reimbursement possible. 

As always, if you have any questions or any clarifications, send me an email at newgenerationbilling@gmail.com. 

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Filed under Administrations, Immunizations, Medical Billing, Office Visit, Preventative services, Vaccinations

When Medicare says 365 days, they mean 365 days.

Gentle readers,

It is flu shot season. And do-the-physicals-on-your-Medicare patients-before-they-go-somewhere-else-and-another-office-bills-the-physical season. And I am seeing a lot of the same question from both my billing service providers, and from you, my gentle readers.

Specifically, you billed/coded the flu shots and physicals the way I taught you and they are still getting denied! What gives?

And here is your unfortunate answer.

Medicare will pay a flu shot once every 365 days. They will pay a physical once every 365 days. They will pay a pap once every 730 days for a woman at normal risk and once every 365 days for a woman at high risk. They will pay the pneumo vaccine once every 365 days.

That means that if a patient came in on Feb 17th 2016 to get their flu shot last year and then came in this year on Jan 25th and got another flu shot, you will not get paid. Even if you bill with ICD10 Z23. Even if you bill with the Q-code for the vaccine. Medicare does not care that it is a different flu season. They do not care that your patient will be visiting their newborn grandson in a couple weeks and they need to be up to date on their immunizations. They do not care that your patient is going for a month long cruise in the caribbean and this is the last date they have available until they get back and they would prefer to get it done before they are rubbing elbows with a bunch of strangers who may have the flu.

Medicare does not care.

And they really mean 365 days. Not 364. So, when a patient needs a preventive service, please try and train your doctors and your office staff to check the date the patient received their last preventive service. The Medicare site also has a tab under the eligibility lookup section to check and see when the patient is next eligible for a preventive service. Here is a screenshot of the page and what it looks like:

medicare-prev-screen-shot-1

As you can see, the date the patient is going to be eligible for any specific service is indicated on the right. Flu and Prevnar are not included in this list, so you will need to rely on your records to track those. 

Below is the link to a good website for more information on the Medicare policies for preventive services. 

https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Keep emailing your questions and I’ll keep giving you answers. 

 

 

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Filed under Flu Shot, Immunizations, Medical Billing, Medicare, Preventative services, Vaccinations