(Medicare Claims Processing Manual)

 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.   Once a Medicare beneficiary has agreed to behavioral counseling sessions, the counseling sessions are to be completed based on the 5As approach adopted by the United States Preventive Services Task Force (USPSTF.)  The steps to the 5As approach are listed below.   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 patients 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.  180.2 - Institutional Billing Requirements  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   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 all -inclusive payment rate    Federally Qualified Health Centers (FQHCs) -  TOB 77X  only -  based on the all -inclusive 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.  180.3 - Professional Billing Requirements  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when services are submitted by the followi ng provider specialties found on the providers enrollment record:   01 - General Practice  08 - Family Practice  11 - Internal Medicine  16 - Obstetrics/Gynecology 37 - Pediatric Medicine  38 - Geriatric Medicine  42 - Certified Nurse -Midwife  50 - Nurse Practitioner  89 - Certified Clinical Nurse Specialist 97 - Physician Assistant   Any claims that are not submitted from one of the provider specialty types noted above will be denied.  For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when submitted with one of the following place of service (POS) codes:   11 - Physicians Office  22 - Outpatient Hospital 49 - Independent Clinic  71 - State or local public health clinic or   Any claims that are not submitted with one of the POS codes noted above will be denied.   The alcohol screening/counseling services are payable with another encounter/visit on the same day.  This does not apply for IPPE.   180.4 - Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   A/B MACs (A) and (B) shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavi oral counseling sessions:    For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 and alcohol misuse counseling HCPCS code G0443 with another encounter/visit with the same line item date of service, use group code CO and reason code:   o Claim Adjustment Reason Code (CARC) 97 -  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present    Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a TOB other than 13X, 71X, 77X, and 85X:   o Claim Adjustment Reason Code (CARC) 5 -  The procedure code/bill type is inconsistent with the place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present   o Remittance Advice Remark Code (RARC) M77 -  Missing/incomplete/invalid place of service   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims that contains more than one alcohol misuse behavioral counseling session G0443 on the same date of service:   o Medicare Summary Notice (MSN) 15.6 -  The information provided does not support the need for this many services or items within this period of time.   o Claim Adjustment Reason Code (CARC) 151 -  Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.   o Remittance Advice Remark Code (RARC) M86 -  Service denied because payment already made for same/similar procedure within set time frame.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims that are not submitted from the appropriate provider specialties:   o Medicare Summary Notice (MSN) 21.18 -  This item or service is not covered when performed or ordered by this provider.   o Claim Adjustment Reason Code (CARC) 185 -  The rendering provider is not eligible to perform the service billed. NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   o Remittance Advice Remark Code (RARC) N95 -  This provider type/provider specialty may not bill this service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims without the appropriate POS code:   o Medicare Summary Notice (MSN) 21.25 -  This service was denied because Medicare only covers this service in certain settings.   o Claim Adjustment Reason Code (CARC) 58 -  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.   o Remittance Advice Remark Code (RARC) N428 - Not covered when performed in this place of service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a 12- month period, and denying alcohol misuse counseling sessions HCPCS code G0443 more than four times in the same 12 -month period:   o Medicare Summary Notice (MSN) 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   o Claim Adjustment Reason Code (CARC) 119 -  Benefit maximum for this time period or occurrence has been reached.   o Remittance Advice Remark Code (RARC) N362 - The number of Days or Units of service exceeds our acceptable maximum.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  180.5 - CWF Requirements  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.  Additionally, CWF shall create an edit to allow alcohol misuse br ief behavioral counseling, HCPCS G0443, no more than 4 times in a 12- month period and make this edit overridable.  CWF shall also count four alcohol misuse counseling sessions HCPCS G0443 in the same 12- month period used for G0442 counting from the date the G0442 screening session was billed.  When applying frequency limitations to G0442 screening on the same date of service as G0443 counseling, CWF shall allow both a claim for the professional service and a claim for a facility fee.  CWF shall identify the following institutional claims as facility fee claims for screening services: TOB 13X, TOB 85X when the revenue code is not 096X, 097X, or 098X.  CWF shall identify all other claims as professional service claims for screening services.  NOTE: This does not apply to RHCs and FQHCs.  190 - Screening for Depression in Adults (Effective October 14, 2011)  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   A. Coverage Requirements