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BILLING FOR STD/HIV/VH PREVENTIVE SERVICES

Presented by Beth Platt, BA, MSCFO, Beth Platt and Associates

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Owner and Chief Financial Officer, Beth Platt and Associates, Rochester, NY

DISCLOSURE

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Explain types of billing; Professional/Referred Ambulatory billing versus Institutional/APG billing.

Identify codes for potentially billable services related to STD/HIV/VH prevention services.

Explain documentation/care requirements for selecting E&M level billing codes.

LEARNING OBJECTIVES:

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Describe governance differences between Medicare, Medicaid, and 3rd party payers.

Identify providers who provide billable services.

Understand when and how to bill by time

LEARNING OBJECTIVES:

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What has changed?• The Patient Protection and Affordable Care

Act (PPACA) expanded access to health care & lowered cost barriers to preventive services.

• Requires Medicare & all qualified commercial health plans to cover a list of preventive services graded A & B by the U.S. Preventive Services Task Force (USPSTF) at no cost to the consumer

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HOWEVER….

• For preventive services that must be covered, an office visit cost-share may apply to the office visit (a) if the preventive service is billed separately from the office visit, or (b) if the primary purpose of the office visit is other than the delivery of preventive service and the preventive service is not billed separately from the office visit.

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Copay/Cost Share

• An office visit cost-share may not be applied to the office visit if (a) the preventive service is not billed separately from the office visit and (b) the primary purpose of the visit is the delivery of the preventive service.

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What are Grade A and B?

• A The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

• B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

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Why bill for Preventive Services (PS)?

PPACA with Medicaid expansion:– Increased # of patients with insurance– Increased # /type of PS covered– Insurer cannot charge copays/ or an amount to

go towards deductible on PS - Use Modifier 33– “Grandfathered “ plan exception – time limited

Providers’ barrier of lack of payment for preventive services - no longer exists

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STD Clinics• ARE considered Essential Community

Providers with whom ACOs need to contract to reimburse for providing PS and other public health (PH) services

• Grant and government funding for billable PS likely to decrease = increased need for revenue

• Billing needed to maintain HD safety net services

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Website for list of ECP’s

• This website has a list of ECP’s and directions on how to be added to the list.

• http://hab.hrsa.gov/affordablecareact/ecp.html

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PS Overview• Will not cover Medicaid fee for service• Will highlight general information on

STD/HIV/VH PS and billing codes• Resources for detailed information re: –Description of all PS and documentation

required for each–Populations eligible to receive PS–Billing codes which vary by insurer

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Qualified Provider• For billing purposes:

Nurse practitioner, Certified Nurse MidwifePhysician – MD or DO, PA

• Some exceptions – HIV counseling & testing, immunizations, etc.

• Registered Nurses can provide PS – bill for 99211 E & M Visit

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USPSTF A and B Recommendations

Insurances Must Cover as Preventive Services:

–Screening for: •Chlamydia , Gonorrhea, Syphilis•HIV, Hepatitis B and C

–STI counseling –Preventive /Risk Reduction Counseling

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USPSTF A and B Recommendations Insurances Must Cover as Preventive Services:

–Vaccines: HPV , Hepatitis A and B –Alcohol /Substance misuse: screening

and counseling–Intimate partner violence screening:–Tobacco use counseling and

interventions:–Tobacco use interventions:

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PS Populations are specificExample: STD screening covers women who are pregnant & under 25 AND anyone at Increased Risk = males under age 25, and those with a history of same infection or other STIs, new or multiple sexual partners, inconsistent condom use, sex work, drug useFor each PS Populations, see• http

://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations

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PS Billing Codes are specific• PPACA requires PS codes to be posted on each

insurance web site • Each insurer has specific combinations of CPT

or HCPCS and ICD-9 codes required to bill for PS – must go to PS charts on each web site.

• CPT: Level I procedure codes• HCPCS : Level II procedure codes for which

there are no CPT codes• ICD-9: Diagnostic codes ( ICD-10 soon)

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PS Billing Codes Vary by Insurer

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Medicare - very user friendly page with navigation buttons describing each PS and the billing code combinations they pay

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

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PS Billing Codes Vary by Insurer

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NYS Medicaid Fee for Service : www.emedny.org go to Medicaid updates and look through index

For Medicaid Managed Care or 3rd party - check your regional sites: United Health Care: www.unitedhealthcareonline.comAetna: www.aetna.comCigna: www.cigna.comBlue Cross/Blue Shield: https://www.excellusbcbs.comOTHERS

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PS Billing WITH E & M Visit

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• PS services are often provided along with an E & M visit

• IF a separate PS code exists - Bill the Visit code AND the PS Codes along with Modifier 25 indicating it was a discrete

• service

• If no code exists, Counseling and Care Coordination can be billed by TIME

• This is only applicable to E & M codes 99201-99215• Preventive codes 99381-99397 may cause bundling on all PS

procedure codes.

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Billing by Time

• E/M with Preventive Services may be coded based on Time, ONLY IF provider spent over 50% of the face-to-face part of the visit Counseling and/or on Coordination of care.

• Must document – over 50% of time for counseling and/or

coordination of care– key points of counseling and/or coordination of

care

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Example• An Established Patient presented for CC of

vaginal discharge, History, Exam, MDM done - would have been a 99212 problem focused visit ( 10 min)

• AND provider did 20 minutes of counseling about patient disclosure of intimate partner violence

• So, total of 30 min spent, half on counseling• Bill for 99214 visit

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Established Patient E & M CodingTwo of the key components* must meet or exceed the stated

requirements to qualify for a particular level of service

Visit CPT Code

9921199212

Problem Focused

99213Expanded Problem Focused

99214Detailed

Chief Complaint

Required Required Required Required

History* Minor problem provider, may not see a QP

(can’t bill NYS MA FFS, but

can bill MMC & 3rd party if seen

by RN)

1-3 HPI1-3 HPI1 ROS

4 HPI2 – 9 ROS

1 pertinent PFSH

Exam* 1-5 bulleted elements

6 bulleted elements

12 bulleted items

Medical Decision Making*

Straightforward Low Moderate

Time (min.) 5 10 15 25

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New Patient - E & M CodingThree of the key components* must meet or exceed the stated requirements to qualify for a particular level of service – 1997 CMS

Visit CPT Code99201

Problem Focused

99202Expanded Problem Focused

99203Detailed

99204Comprehensiv

e

Chief Complaint

Required Required Required Required

History* 1-3 HPI1-3 HPI

1 problem pertinent ROS

4 HPI2-9 ROS

1 pertinent PFSH

4 HPI10+ ROS2-3 PFSH

Exam*1-5 bulleted

elements6 bulleted elements

12 bulleted elements

All bulleted items

Medical Decision Making*

Straightforward Straightforward Low Moderate

Time (min.) 10 20 30 45

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PS related ICD-9 Codes

Screening for STD/HIVV70.0 Routine medical examV72.31 Routine GYN examScreening for:

HPV: V73.81 CT: V73.88 HIV: V 73.89 Bacterial STDs - GC, Syphilis: V74.5

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PS related ICD-9 Codes V69 Problems related to life style V69.2 = High Risk Sexual Behavior V69.8 = High Risk GroupV69.9 = Unspecified – could be ETOH or substance user, homeless, incarcerated, conditions affecting diagnosis or management

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PS related ICD-9 Codes

Counseling V65.40 = Counseling NOSV65.42 = Counseling on ETOH/SUV65.44 = HIV CounselingV65.49 = Other specified counseling

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PS related ICD-9 Codes Contact with or Exposure to: V01.6 = Bacterial STDsV01.79 = Other viral – HIV, VH, HSV Carrier or Suspected Carrier:V02.61 = Hep BV02.62 = Hep CV02.7 = GC V02.8 = Other venereal diseases, syphilis

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PS related HCPCS Procedure Codes G0010=Admin Heb B VaccineG0443=ELISA Infectious agent antibody detectinG0432 = HIV antibody EIA HIV 1 or 2 screeningG0435 = HIV antibody EIA rapid, oral HIV 1 or 2 G0436 = Smoking cessation counseling 10 minG0437= Smoking cessation more than 10 minG0442 = ETOH ScreeningG0443 = ETOH Brief Intervention 15 minG0444 = Annual Depression ScreeningG0445 = HIBC – sexual risk reduction counselingG0472: Hepatitis C antibody screening for individual at high risk and other covered indication(s)

Medicare and some 3rd party pay G Codes6-12-15

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Chlamydia & Gonorrhea Screening

CPT Procedure codes• 87110 – CT culture• 87320 – CT ELISA• 87491 – CT NAAT • 87081 - GC culture, presumptive, screening• 87591 - GC NAAT• 87801 – CT and GC NAAT• G0445 Counseling to prevent-30 min• Use Diagnosis: V74.5, V69.8, V22.0, V22.1 or V23.9

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Syphilis ScreeningCPT Procedure Codes86592: Syphilis antibody indirect (VDRL, RPR, ART)86593: Quantitative if above is positive – titer86789: Syphilis antibody direct EIA, FTA, TP-PA 36415: venipuncture36416 : blood from lancet/stick G0445-Counseling to prevent 30 minutesUse Diagnosis V73.89, V22.0, V22.1 or V23.9, V69.8

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Hepatitis B, C ScreeningProcedure Codes

86707 – Hep B Antibody 86803 – Hep C Antibody Modifier *92 if rapid kit used86804: Hep C Confirmatory TestG0472: Hepatitis C antibody screening for individual at high risk and other covered indication(s) – can have yearly, must use V69.8 – high risk group36415 – Venipuncture , 36416 – Finger stick Use Diagnosis Hep B: V69.8, V73.89,V22.0, V22.1, V23.89Hep C-Once in a lifetime if born between 1945-1965Hep C Once yearly if High Risk/continued drug use. V69.8 with 304.91

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HIV ScreeningProcedure Codes86689 – Western Blot – used to be confirmatory86701 – HIV type 1 antibody * Modifier 92 86702 – HIV type 2 antibody86703 – HIV type 1 and 2, single result 87389 – 4rth Gen HIV antibody and antigen *Modifier 9287535 – HIV NAAT 36415 – Venipuncture , 36416 – Finger stick G0432 – HIV antibody EIAG0433 – HIV antibody EIA, rapid , oral G0435-RapidUse Diagnosis V73.89, V69.8, V22.0, V22.1, V23.9 Annually or if pregnant 3 times during pregnancy.

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Preventive Medicine Counseling • Any Risk Reduction counseling to prevent a

health problem - based on the approximate duration of service:

• 99401- 15 minutes– If between 8-15 minutes add modifier U5– If under 8 minutes DO NOT BILL

• 99402 - 30 minutes• 99403 - 45 minutes• 99404 - 60 minutes

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Sexual Risk Reduction Counseling • 99401-99404: Preventive medicine

counseling and/or risk factor reduction intervention, time-based in 15 min intervals ( Medicaid pays this on an institutional claim)

• G0445: High Intensity Behavioral Counseling to Prevent STIs - individual, face to face, includes education skills training and guidance on how to change sexual behavior (30 minutes-semi annually) (Medicare/Excellus pay this code)

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Health Risk Assessment • CPT 99420 (Administration and Interpretation

of a risk assessment instrument) for any type of health problem ( cardiovascular, depression, sexual risk, etc.)

• Screening for ETOH/SU and Tobacco have separate CPT codes, but an insurance co may choose to use 99420 for all screening

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Hep B , A, and HPV VaccinesSeparate CPT codes for each type of vaccineFor Vaccine Administration:• Initial vaccine: CPT 90460 ( any type vaccine 18

yrs. and younger) or 90471 (injectable vaccine for over 18)

• cannot bill more than one Initial code on the same date of service.

• Additional vaccines on same day, code 90461 (any type second vaccine 18 or younger ) or 90472 (each injectable vaccine for adults over 18).

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Alcohol/SU Misuse: Screening and Brief Intervention • Screening is usually done using published tools. http://

www.oasas.ny.gov/AdMed/sbirt/index.cfm AUDIT, ASSIST, CRAFFT, DAST-10, POSIT, CAGE• Tools must provide information to tailor an intervention to

the identified level of ETOH/SU and must include:• An in-person interview• Quantity/frequency of substance use over a particular time

frame (generally 1-12 months)• Problems related to use • Dependence symptom• Injection drug use.

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Alcohol /SU Screening , Intervention

• S = Screening• BI = Brief Intervention• Can do S only

For some insurers:• G0442 = ETOH screen

15 min• G0443 = ETOH BI 15 min

• Procedure code for S = H0049

• Use with Diagnosis code for S = V82.9

• Procedure code BI = H0050

• Use with Diagnosis code BI = V65.2

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Definition – ETOH/SU Brief Intervention

• NY Medicaid does not endorse a specific model, ex. FRAMES

• Providers must use effective strategies intended to motivate individuals to decrease or abstain from ETOH/ SU

• Examples of effective strategies can be found on www. samhsa.gov

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Smoking Cessation - Intermediate• Diagnosis code 305.1 on claim, can be sole

reason for visit• Up to 6 sessions in a consecutive 12-month

period• CPT 99406 – smoking cessation counseling

for a 3-10 minute individual session

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Smoking Cessation - Intensive• CPT 99407 – intensive smoking cessation

counseling greater than 10 minutes and may be a group (Use modifier HQ)

• Claim may contain other CPT codes for HIV counseling and or E&M codes

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Tobacco use counseling and interventions

• Medicare uses G0436 for 3-10 minutes and G0437 for greater than 10 minutes.

• Other insurances may use those codes also, or the 99401-99407 series of codes.

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Intimate Partner Violence screening

• This service is usually included in an exam code 99201-99215.

• Remember, if counseling is provided for more than 50% of the visit, may bill by Time

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E & M Visits & PS• Document the CC, History, Exam, MDM • Bill the appropriate E & M visit CPT/ICD-9

code that reflects the service rendered • Add the PS codes IF they were provided as a

discrete service in addition to the E & M visit• If no codes for the PS provided , consider

billing by Time as the controlling factor

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Nurse Visit – E & M 99211• For an Established Patient• A nurse can provide a PS• Can bill E & M 99211• All Medicaid Managed Care and other 3rd

party will pay - but not Medicaid FFS

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In Conclusion1. If separate coding – PS can be billed on top

of the E & M visit CPT code IF they were provided as a discreet separate service

2. IF no separate coding - E & M visits can be billed by Time spent if over 50% of time was spent on PS related counseling

3. NYS Medicaid Managed Care and Private providers pay for 99211 visits for services provided by a nurse.

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Useful Websites• List of helpful websites:• For Essential Community Providers a list is available at:• http://hab.hrsa.gov/affordablecareact/ecp.html• To obtain an NPI:• https://nppes.cms.hhs.gov/NPPES/Welcome.do• To obtain Medicare enrollment forms:• http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupE

nroll/EnrollmentApplications.html• To obtain ETIN Certification forms and enrollment/EFT forms for NY Medicaid:• https://www.emedny.org/info/ProviderEnrollment/• To complete the OMIG CCSL:• www.omig.ny.gov• To complete the CAQH application• http://www.caqh.org/access-upd.php• To watch the CAQH tutorial• http://www.caqh.org/upd-tutorial.php• To obtain Model HIPAA notices• http//www.hhs.gov/ocr/privacy/hipaa/modelnotices.html• 6-12-15

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QUESTIONS?

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