Coding Corner: Behavior Change Interventions
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Codes for "Behavior Change Interventions, Individual" were added to the CPT code set in 2008. There are two codes for smoking cessation counseling (99406-99407) and two for substance abuse structured screening and brief intervention (99408-99409). The CPT manual states that these services "involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services and follow-up." The codes may be reported when the intervention is performed as part of the treatment for a condition that is being aggravated by smoking or substance abuse, or to prevent future illness in a patient who has not yet developed any complications from the behavior. The codes are time-based and can be reported for both new and established patients.
Bilateral Procedures and Duplicated Collecting Systems
The CPT preventive service guidelines were revised for 2016 to clarify that behavior change intervention can be reported together with preventive visits (99381-99397). Also, the guidelines state that behavior change interventions are "distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed." In other words, these interventions can be reported in conjunction with either a problem-oriented visit or a well patient visit, provided that both the behavior change intervention and the problem-oriented or preventive E/M service are appropriately documented. Modifier 25 should be applied to the E/M code to indicate it is separate and distinct from the behavior change intervention.
Smoking and Tobacco Use
There are two CPT codes for smoking cessation counseling:
|99406||Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes|
|99407||. . . intensive, greater than 10 minutes|
There must be a minimum of four minutes of counseling; lesser amounts are included in the associated E/M service. Code 99406 is assigned for 4-10 minutes of counseling, and code 99407 is assigned for greater than 10 minutes of counseling. As with any time-based service, there must be documentation of the service time (face-to-face time) in the medical record.
By CPT coding guidelines, codes 99406 and 99407 can be used for counseling of both symptomatic and asymptomatic patients. However, Medicare recognizes these codes only for counseling of symptomatic patients. CMS defines a symptomatic patient as one who:
- has a disease or adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use; or
- is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on FDA-approved information.
For example, a patient with lung cancer or emphysema caused by smoking would be considered a symptomatic patient, and his counseling would be reported to Medicare with 99406-99407.
Counseling of asymptomatic patients is reported to Medicare using the following HCPCS codes:
|G0436||Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes|
|G0437||. . . intensive, greater than 10 minutes|
Counseling of asymptomatic patients is classified as a preventive service, and copayment/coinsurance and deductible are waived. Modifier 33 (Preventive Services) is not required with codes G0436 and G0437, since they are preventive by definition.
In order for Medicare to cover either type of smoking cessation counseling, the following requirements must be met:
- The patient uses tobacco.
- The patient is competent and alert at the time that counseling is provided.
- The counseling is furnished by a qualified physician or nonphysician practitioner.
Regardless of whether the patient is symptomatic or asymptomatic, Medicare will cover two cessation "attempts" per patient per year. Each attempt may include a maximum of four intermediate or intensive sessions, so the annual maximum is eight sessions. The physician and patient can choose whether the sessions will be intermediate (4-10 minutes) or intensive (more than 10 minutes).
In order to report a smoking cessation counseling code, the physician or practitioner must provide actual counseling, not just a review of the patient's tobacco use history. CMS recommends using printed materials that federal agencies have developed to help people quit smoking. For example, the smokefree.gov website offers a variety of resources, including the quitSTART app for teenagers.
Example #1: An established Medicare patient presents to his primary care physician with complaints of wheezing and shortness of breath. The physician documents a Level 4 visit with an impression of chronic asthmatic bronchitis due to smoking (40 pack-years). The physician prescribes bronchodilators and also provides seven minutes of face-to-face smoking cessation counseling. The physician's codes for these services are 99214-25 and 99406. This patient is symptomatic, so the smoking cessation counseling is reported with CPT codes 99406-99407 rather than HCPCS codes G0436-G0437.
Example #2: A new Medicare patient is seen for complaints of burning during urination. When the physician takes the social history, the patient states that she smokes a pack of cigarettes per day and has tried several times to quit, but without success. The physician documents a Level 3 visit, prescribes antibiotics for the patient's urinary tract infection, and also spends eight minutes counseling the patient about her smoking and techniques that may help her quit. The physician's codes for these services are 99203-25 and G0436. Since this patient is asymptomatic from her smoking at this time, the physician should use the HCPCS codes for smoking cessation counseling.
Alcohol and Substance Abuse
The following CPT codes represent screening and brief intervention (SBI) for alcohol and/or substance abuse:
|99408||Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes|
|99409||. . . greater than 30 minutes|
These services require the use of a standardized questionnaire to evaluate the patient's substance use. For example, the Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization to evaluate patients' alcohol use. Scores range from 0 to 40, and a score of 8 or more indicates a harmful level of alcohol consumption. Similarly, the Drug Abuse Screening Test (DAST) asks for yes/no responses to 28 questions about drug use, and a score over 12 indicates a substance abuse problem.
After the patient completes the screening, the physician or nonphysician practitioner educates the patient about the test results, discusses the importance of reducing intake, and – if necessary – refers the patient for further services.
Services lasting less than 15 minutes are included in the associated E/M service. Report 99408 for SBI lasting 15-30 minutes and 99409 for SBI lasting more than 30 minutes.
Medicare does not reimburse for CPT codes 99408 and 99409, both of which are listed in the Medicare Physician Fee Schedule Relative Value File as status N (noncovered services). However, Medicare does provide limited coverage of this service when billed by certain provider types using HCPCS codes. The service must be billed by a primary care provider, such as a family practitioner, internist, geriatric medicine specialist, nurse practitioner, or physician assistant. For a complete listing, see the Medicare Claims Processing Manual, chapter 18, section 180.3.
CMS states that the service consists of the following components, abbreviated "SBIRT":
- Structured assessment
- Brief intervention
- Referral to treatment
SBIRT must be reported to Medicare using one of the following HCPCS codes:
|G0396||Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST), and brief intervention 15 to 30 minutes|
|G0397||. . . greater than 30 minutes|
Medicare will cover the screening – reported with code G0442 – on an annual basis. Additionally, for patients who screen positive, Medicare will cover up to four face-to-face counseling interventions per year, reported with code G0443.
For more information about Medicare coverage of SBIRT, please see the following CMS booklet: go.cms.gov/218R75o.
Incentives for Healthy Behavior
Helping patients eliminate unhealthy habits is an important part of any healthcare provider's mission, and CMS has acknowledged the importance of behavior change interventions by establishing reimbursement for them. For complete information about these and other covered preventive services, please see the Medicare preventive services webpage at go.cms.gov/1VQlk9x.
Jackie Miller, RHIA, CCS-P, CPC, is vice president of product development at Coding Strategies, Inc.