by Wyn Staheli
December 28th, 2017
Codes G0442 (screening) and G0443 (15 min counseling) are typically a covered preventive service for most payers. As a preventive service, copayment/coinsurance and deductibles are typically waived. These are NOT considered treatment services or sessions for alcoholism or other substance abuse. If the screening results indicate that the patient is dependent and is open to the idea of additional counseling, consider codes 99408 or 99409. Medicare will typically cover G0396 or G0397.
Screening (G0442) Requirements:
Medicare does not limit the type of screening tool used. The Alcohol Use Disorders Identification Tool (AUDIT) is one commonly used tool.
Behavioral Counseling Intervention Requirements:
Note that this is a timed service so time requirements must be adhered to. In addition the face-to-face or telehealth requirement, Medicare requires the following to be documented:
- Assess: Ask about/assess behavioral health risk(s) and factors that may affect the choice of goals/methods used to change behavior.
- Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
- Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
- Assist: Using behavior change techniques (self-help and/or counseling), to aid the patient in achieving agreed-upon goals by helping them to acquire the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
- 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.
Medicare Coverage Information:
- G0442 once per year and if the patient screens positive, 4 counseling sessions (G0443) are also covered.
- Dependence is defined as meeting at least 3 of the following:
- Withdrawal symptoms
- Impaired control
- Preoccupations with acquisition and/or use
- Persistent desire or unsuccessful efforts to quit
- Sustains social, occupational, or recreational disability
- Use continues despite adverse consequences
- The patient must be competent and alert when face-to-face (or telehealth where applicable) counseling is provided.
- Counseling provided by a primary care provider (e.g., doctor or nurse practitioner) in a primary care setting (e.g., doctor's office or clinic).
- Screenings provided in any of the following settings are are not covered:
- Ambulatory surgical center
- Emergency department
- Independent diagnostic testing facility
- Inpatient hospital setting (outpatient may be covered if other criteria are met)
- Inpatient rehabilitation facility
- Skilled nursing facility
- It is not part of the Initial Preventive Physical Examination (IPPE) or the Annual Wellness Visit (AWV) so it's a standalone billable service.