United Healthcare really does not like to pay for depression and drug screenings.

One of my providers does a PHQ9 and a dependency screening with each physical. I know most doctors don’t think it is necessary, but this provider tells me they have seen so many patients who don’t bring up their mental health or substance abuse issues verbally during their medical visits. Those patients consistently have worse outcomes because the treatment often changes when taking those conditions into account. Doing the written tests with the physical allows patients to be truthful in a low stakes environment. Those tests are then scored and the results shared with the patient; whether they end up being positive or negative. 

This is extra work. And if your providers do these, they deserve to be paid for that extra work. 

Most insurances acknowledge that and pay separately. While CMS did just update their guidelines to state that the depression screening code G0444 is not payable with an annual wellness, insurances will still pay the PHQ9 separately with 96127. 

But not United Healthcare. I found these guidelines from United Healthcare regarding their physical and screening policy and they are very straightforward. UHC is very clear that they believe codes G0444, G0442, 99408, G0396, G0447, and 99406 are included as part of a physical. If I sound irritated, it’s because I am. It is my job to ensure that my providers get paid for every service they perform. When my provider is taking 10-15 minutes more per physical on these two services, that is 10-15 minutes that they are not seeing other patients. That is an entire calendar slot that could be used for another patient. 

Rant over. 

There are two codes that are not on this excluded list that cover both a depression screening and a dependency screening and UHC will pay them separately about 60% of the time. Use S3005 for the depression screening and H0049 for the dependency screening. UHC will pay $24.00 for the S3005 and $10.00 for the H0049. Not always (because it depends on the patient’s plan) but $34.00 for 60% of the UHC screenings is better than $0.00 for 100% of the UHC screenings. 

If you are having trouble getting your additional services paid, give me a call at (909) 610-9524 or send me an email at newgenerationbilling@gmail.com and I’ll give you a hand. 

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!