by Jared Staheli
July 7th, 2015
For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and brief, face-to-face behavioral counseling for alcohol misuse, 15 minutes, G0443 for:
• Rural Health Clinics (RHCs) - type of bill (TOB) 71X only – based on the allinclusive payment rate
• Federally Qualified Health Centers (FQHCs) - TOB 77X only – based on the allinclusive payment rate
• Outpatient hospitals – TOB 13X - based on Outpatient Prospective Payment System (OPPS)
• Critical Access Hospitals (CAHs) - TOB 85X – based on reasonable cost
• CAH Method II – TOB 85X - based on 115% of the lesser of the Medicare Physician Fee Schedule (MPFS) amount or actual charge as applicable with revenue codes 096X, 097X, or 098X.
For RHCs and FQHCs the alcohol screening/counseling is not separately payable with another face-to-face encounter on the same day. This does not apply to the Initial Preventive Physical Examination (IPPE), unrelated services denoted with modifier 59, and 77X claims containing Diabetes Self Management Training (DSMT) and Medical Nutrition Therapy (MNT)services. DSMT and MNT apply to FQHCs only. However, the screening/counseling sessions alone when rendered as a face-to-face visit with a core practitioner do constitute an encounter and is paid based on the all-inclusive payment rate.
Note: For outpatient hospital settings, as in any other setting, services covered under this NCD must be provided by a primary care provider.
Claims submitted with alcohol misuse screening and behavioral counseling HCPCS codes G0442 and G0443 on a TOB other than 13X, 71X, 77X, and 85X will be denied.
Effective October 14, 2011, deductible and co-insurance should not be applied for line items on claims billed for alcohol misuse screening G0442 and behavioral counseling for alcohol misuse G0443.
References:
Quick, Current, Complete - www.findacode.com