Medicare Update: How to Get Paid for Depression and Alcohol Misuse Screening and Obesity Counseling in a Primary Care Practice

“Medicare pays primary care clinicians for Behavioral Health services? Since when?”

Here's a Medicare update of particular interest to primary care practices: The Accountable Care Act of 2010 mandated that Medicare cover any services that the US Preventive Task Force rated with an A or B, services supported by evidence-based medicine. But, before beginning the celebrations, take a close look at the Relative Value Units (RVUs) for the services and the payment rules.

CMS has released transmittals and MLN Matters articles for two of these:

1) Screening and behavioral counseling interventions in primary care to reduce alcohol misuse and

2) Screening for depression in adults.

For the third, Intensive Behavioral Therapy for Obesity, CMS released a coverage determination but has yet to release the transmittal or MLN Matters articles. RVUs for all of these services are in the 2012 Physician Fee Schedule.

Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: This benefit provides for an annual screening for alcohol misuse, and for those who screen positive, four brief, face-to-face behavioral interventions annually for Medicare beneficiaries. Alcohol misuse is defined as >7 drinks per week or >3 drinks per occasion for women, and >14 drinks per week or >4 drinks per occasion for men.

Harmful drinking describes those persons currently experiencing physical, social or psychological harm from alcohol use, but who do not meet criteria for dependence. The counseling must be furnished by primary care clinicians in a primary care setting. In order to provide the service, the clinician must be signed up with Medicare in one of these specialties:

• General Practice
• Family Practice
• Internal Medicine
• OB/GYN
• Geriatrics
• Pediatrics
• Certified Nurse Midwife
• Nurse Practitioner
• Certified Clinical Nurse Specialist
• Physician Assistant

The services must be supplied in a physician office, outpatient hospital, independent clinic or state or local public health clinic to be reportable.

The codes are time-based, so document time in the medical record. G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes). G0442 and G0443 may be provided on the same date of service.

Annual depression screening: CMS will also pay primary care clinicians to screen patients annually for depression, also a time-based code. Both the transmittal and the MLN Matters article imply that staff can do some of the screening:

“At a minimum level, staff-assisted depression care supports consist of clinical staff (e.g., nurse, Physician Assistant) in the primary care office who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment. More comprehensive care supports include a case manager working with the primary care physician; planned collaborative care between the primary care provider and mental health clinicians; patient education and support for patient self-management; plus attention to patient preferences regarding counseling, medications, and referral to mental health professionals with or without continuing involvement by the patient’s primary care physician.”

Neither the transmittal nor the MLN article specifically say if this service may be provided on the same day as an office visit, but the services are not bundled and it would appear that the depression screening could be provided on the same day as a problem-oriented visit.

G0444 is the code for annual depression screening, 15 minutes.

Face-to-face behavioral counseling for obesity: CMS has also developed a HCPCS code for intensive behavioral therapy for obesity, which consists of screening based on BMI, dietary assessment and intensive behavioral counseling and behavioral therapy to promote sustained weight loss. CMS will cover one face-to-face service weekly for the first month, one face-to-face visit every other week for months two to six, and one face-to-face visit every month for months seven to twelve, if the beneficiary has a weight reduction of 3 kg during the first six months. These services must also be performed by a primary care practitioner. For the purposes of this benefit, a PCP is defined as a physician who has a specialty designation of Family Medicine, Internal Medicine, Geriatric or Pediatric Medicine. A nurse practitioner, physician assistant or clinical nurse specialist may also provide these services.

G0447 Face-to-face behavioral counseling for obesity, 15 minutes.

The coverage for these services is good news. But, the payment for the services is not high. All of the services are defined as 15-minute visits, and with only .51 or .74 total RVUs, will not pay very much. Still, some primary care practices will want to incorporate these services into their practices. Remember to document time in the medical record.

Code	Description	Work RVU	Total RVU
G0442	Annual alcohol misuse screening, 15 minutes	0.18	0.51
G0443	Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes	0.45	0.74
G0444	Annual depression screening, 15 minutes	0.18	0.51
G0447	Face-to-face behavioral counseling for obesity, 15 minutes.	0.45	0.74

CMS Transmittal and MLN Matters article for alcohol counseling

CMS Transmittal and MLN Matters for depression screening

CMS National Coverage Determination on obesity