The Centers for Medicare and Medicaid Services continues to expand the range of screening and counseling services that are covered by Medicare. In late 2011, CMS started covering four screening and behavioral assessments for alcohol misuse, depression, sexually transmitted infections and obesity.
New Health Care Procedure Coding System (HCPCS) codes have been issued for reporting these services. The billing codes, all timed, cannot be reported in multiple units. Beneficiary co-insurances and deductibles do not apply to these benefits.
All four of these services must be provided by a primary care setting, which CMS defines as “one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospice are not considered primary care settings under this definition.”
Also, a primary care physician is defined by CMS as a physician who is identified in the Medicare enrollment records as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.
Screening for alcohol misuse
Alcohol misuse screening and behavioral counseling interventions will be covered for certain beneficiaries who have Medicare Part A and/or Part B. The screening and interventions must be provided by qualified primary care physicians or “other primary care practitioners” and take place in primary care settings.
For those who screen positive, up to four brief, face-to-face behavioral counseling interventions per year will be covered. The benefit is provided for beneficiaries, including pregnant women:
- who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, continued use despite adverse consequences, and sustained social, occupational, or recreational disability), and
- who are competent and alert at the time that counseling is provided.
For claims reporting purposes, CMS created these HCPCS codes:
- G0442-annual alcohol misuse screening, 15 minutes
- G0443-brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Annual depression screening in adults will be covered for certain beneficiaries who have Medicare Part A and/or B. The screening must take place in primary care settings that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up and must be provided by qualified primary care physicians or other primary care practitioners.
CMS specifies that, at a minimum level, staff-assisted depression care supports must consist of clinical staff such as nurses and physician assistants in the primary care setting who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment. (See “CPII Tips” for more information.)
The CMS decision focuses only on identifying depressed patients in primary care settings and the need for staff-assisted support systems to assure their accurate diagnosis, effective treatment, and follow-up. The decision memo does not address treatment options, nor any diseases, complications or chronic conditions resulting from depression. Self-help materials, phone calls, and Web-based counseling are not paid separately by Medicare and are not covered.
For claims with dates of service on or after April 2, 2012, Medicare contractors will pay annual depression screenings reported with G0444 for only the following places of service (listed with their respective place of service codes): office (11), outpatient hospital (22), independent clinic (49), federally qualified health center (50), state or local public health clinic (71), and rural health clinic (72).
Coverage for sexually transmitted diseases
CMS will cover screening for the sexually transmitted infections (STIs) chlamydia, gonorrhea, syphilis, and hepatitis B with the appropriate FDA approved/cleared laboratory tests, used according to FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations.
The tests will be covered when ordered by the primary care clinician and performed by a clinician Medicare considers eligible to provide these services.
CMS will also cover up to two individual, 20- to 30- minute, face-to-face counseling sessions. These limits are per year. The benefit is available to all sexually active beneficiaries (adolescents and adults) who are at increased risk for STIs if they are referred for this service by a primary care clinician and if the service is provided by a Medicare-eligible primary care clinician in a primary care setting.
CMS created HCPCS code G0445 for high-intensity face-to-face, individual behavioral counseling to prevent sexually transmitted infection (includes education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes). The previous STI screening code, G0450, has been deleted and should not be used.
Intensive obesity therapy
Medicare beneficiaries with obesity, measured by a body mass index (BMI) greater than or equal to 30 kg/m2, are eligible for:
- one face-to-face visit every week for the first month;
- one face-to-face visit every other week for months 2 to 6; and
- one face-to-face visit every month for months 7 to 12.
The benefit is applicable to those who are competent and alert when counseling is provided.
The obesity counseling should be reported with the new HCPCS code G0447 (face-to-face behavioral counseling for obesity, 15 minutes).