“Alcohol consumption among older adults in the U.S. has grown steadily over the past couple of decades. Between 2002 and 2006, an average of 2.8 million adults over the age of 50 suffered from substance use disorders, including alcoholism. By 2020, that number is projected to double, totaling roughly 5.7 million seniors.”  Alcoholism in Seniors

There are several situations that may lead to excessive drinking in older individuals include:

  • Empty nest syndrome (when children grow up and move away)
  • Loss of friendships due to moves, health complications or death
  • Deteriorating health conditions (cardiovascular disease, vision/hearing loss and diabetes)
  • Traumatic events like a spouse’s illness or death
  • Sadness after downsizing a home
  • Boredom from retirement or lack of socialization

Background:

According to the USPSTF (2004), alcohol misuse includes risky/hazardous and harmful drinking which place individuals at risk for future problems; and in the general adult population, risky or hazardous drinking 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.

Two codes have been designated for billing for Preventive Screening and Treatment by Medicare:

  • G0442 (Annual Alcohol Misuse Screening, 15 minutes), and
  • G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes)

Screening:

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare 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, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,
  • who are competent and alert at the time that counseling is provided; and,
  • whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

Treatment:

Each of the four behavioral counseling interventions must be consistent with the 5As approach that has been adopted by the USPSTF to describe such services:

  1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

For more information regarding integrating behavioral intervention into a medical practice we encourage you to visit our how to article/blog posting Promoting Effective Behavioral Change in Primary Care.

Billing Options:

The above requirements are for Codes G0442 and G0443.  These two codes are the recognized preventive service codes assigned for alcohol abuse screening and treatment.

Medicare also offers two codes for Screening, Brief Intervention, and Referral to Treatment or SBIRT.  Note this service is different from the normal Annual Screening and Treatment listed in Medicare’s Preventive Service Guide.

  • Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30min
  • Medicare G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30min

SBIRT:

The Screening, Brief Intervention, and Referral to Treatment program is nationally recognized as one of the best way to screen for and treat patients who may have a problem with alcohol.  This article however, is written specifically for the Medicare Preventive Service program.  That being said, we encourage providers to visit the SAMHSA-HRSA Center for Integrated Health Solutions Website to understand SBIRT and the benefits of this program to primary care recipients.

SBIRT is considered one of the most successful ways to support alcohol abuse screening and treatment in primary care.  That being said, our research has indicated concerns regarding integrating SBIRT into Medicare Preventive Services G0442 and G0443.  If your practice intends to utilize SBIRT for billing codes G0442 and G0443, we highly recommend your billing and internal audit staff review the requirements of G0442 and G0443 with the program guides of SBIRT to ensure the practice can remain in compliance with Medicare’s regulations with those codes before integrating these services.  Further assistance on integrating these SBIRT into G0442 and G0443 may be found at the Guide for SBIRT Reimbursement Website.

Clinic Within A Clinic ™

As with recommendations we have made with other preventive services, we believe many if not most of Medicare’s requirements can be met by highly trained nurses and other staff.  As with regular E&M services, a provider must supervise the skilled nurses and must always see the patient before the visit is completed.  The only preventive service a provider is not required to see the patient before billing can occur is the Medicare Annual Wellness Visit.

Most practices do not use the preventive service codes such as G0442 and G0443 because of the lack of reimbursement and time constraints created by the often onerous requirements for these services.  This is where a trained wellness staff can be a significantly beneficial element to implementing these and other preventive services.

Federally Qualified Health Centers (FQHCs):

FQHCs bill based upon the new Prospective Payment System (PPS) which is a flat rate agreed upon by CMS.  A FQHC may not bill for services not listed within the PPS system.  Both G0442 and G0443 are listed as services billable by FQHCs using the PPS rate.

CMS has interpreted the Social Security Act to state that a provider must see all patients who come to the FQHC for care before billing may occur.  As with the Fee for Service providers, the provider should be included in the alcohol screening and treatment process.  The wellness team should still play a significant part of the visit but it is important to note that CMS’s Regulations and Guidance paper states:

“When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered “incident to” and do not constitute a billable visit.”

To avoid the “incident to” scenario, the FQHC must define clearly what the wellness staff will do during the tobacco cessation visits delineating the appropriate activities that can be done by the wellness staff and then what elements of the visit must be done by the provider.  

We recommend the practice set the wellness program up similar to how a regular E&M service works… LPNs and RNs are assigned tasks and the provider follows up with the appropriate patient interactions.

Conclusion:

People who drink too much alcohol increase their risk of injuries, violence, drowning, liver disease, and even some types of cancer. Studies indicate that providers even with brief interventions can have a significant impact on reducing their patient’s over consumption or abuse of alcohol.

Integrating an alcohol screening and treatment program into a practice can be a beneficial way to increase long term patient outcomes.

If you would like to learn more about building a wellness program in your practice please visit our article/blog Building a Medicare Prevention/Wellness Program is Difficult, We Want To Help

Other Preventive Services Explained:

Basic Introduction to the Medicare Annual Wellness Visit

Building Your Primary Care Weight Loss Program For Medicare Patients

Intensive Behavioral Therapy for Cardiovascular Disease; How it Works in Primary Care Settings

How To Integrate Depression Screening and Treatment In A Primary Care Environment

How to integrate Tobacco Cessation in a Primary Care Medicare Wellness Program

Compassionate Healthcare, A Guide To Advance Care Planning In The Primary Care Setting