tci Medicare Compliance & Reimbursement - 2007 Issue 42
CPT 2008: Look For Drug-Abuse Questions In E/M Notes, And Add To Your Revenue
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Article Overview
This article covers a 2008 CPT update involving substance-abuse screening in the context of evaluation and management visits. It is aimed at coders, billers, and clinicians in settings where screening for alcohol or drug misuse may be documented. The discussion focuses on the general documentation elements, time-based reporting, and the role of structured questionnaires and brief intervention in support of the new screening codes.
Why This Topic Matters
The topic matters because it highlights a change that may affect how substance-abuse screening is captured alongside office visits, which can influence compliant charge capture and documentation practices. It is especially relevant for practices that routinely evaluate pain, controlled-substance use, or possible alcohol and drug misuse.
Article Sections
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Doctor must document time, structured questionnaire
Introduces the topic and frames the documentation and reporting issues associated with the screening update. It also situates the discussion in routine office-based care.
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The lowdown
Summarizes the screening-related update and its connection to evaluation and management services. It explains the general setting in which the guidance applies.
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Example
Presents a broad clinical scenario illustrating the type of visit where the screening topic may come up. The section is used to show the practical context without giving coding instructions.
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What to document
Describes the types of documentation elements discussed in connection with the screening service. It emphasizes the need for structured support without revealing detailed selection criteria.
What You Will Learn
- The general purpose of the 2008 substance-abuse screening update
- How the article relates screening documentation to evaluation and management visits
- What kinds of documentation elements are discussed in connection with screening
- Which practice settings are most likely to encounter this topic
Who Should Read This
- Medical coders
- Billing staff
- Primary care practices
- Pain management practices
- Clinicians documenting office visits
Codes Discussed
Code Ranges Discussed
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