Reimbursement for Alcohol Misuse Screening

Medicare Benefit

• Reimbursement screening for alcohol misuse in adults including pregnant women once per year under Fee-for-Service Medicare benefit since October 14, 2011. No coinsurance; no deductible for patient.
• Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Alcohol Misuse Includes “Risky/Hazardous” and “Harmful” Drinking, and is distinct from “Alcohol Dependence”

• Risky/Hazardous Drinking: Frequency of drinking (drinks/week or drinks/occasion) that exceeds recommended drinking limits and that increases an individual’s risk for future alcohol-related problems.
• Harmful Drinking: drinking pattern that is currently causing harm (e.g., family, health, legal, employment) but does not meet criteria for alcohol dependence.
• Alcohol Dependence (i.e., Addiction): defined by three or more of the following: tolerance; withdrawal; alcohol use often greater than intended; unsuccessful efforts to control alcohol use; a great deal of time spent in alcohol-related activities; important social, occupational, or recreational activities reduced or given up because of alcohol use; alcohol use continued despite knowledge of physical or psychological problem that is likely caused by alcohol use (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).

Value to you and your patients

Screening in primary care settings can identify patients who misuse alcohol. Early interventions and follow-up can reduce alcohol consumption and improve health outcomes.

•  Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse
• The Alcohol Use Disorders Identification Test

Procedure Code

G0442 – Annual Alcohol Misuse Screening, 15 minutes

Eligibility

Eligible Primary-Care Clinicians:

• General practice, family practice, internal medicine, obstetrics/gynecology, pediatric medicine, geriatric medicine, certified nurse midwife, nurse practitioner, certified clinical nurse specialist, physician assistant

Eligible Places of Service:

• Physician’s office, outpatient hospital, independent clinic, state or local public health clinic
• Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Referral Options

If referring a patient for post-screening assessment or treatment, contact local outpatient substance abuse program or mental health organization. Referral assistance available at the following sites:

• Clinicians Support Guide 2005
• A Guide to Substance Abuse Services for Primary Care Clinicians – Chapter 5

Commonly Used Evidence-Based Screening Tools

Alcohol Use Disorders Identification Tool (AUDIT) can be completed by patient and scored quickly by staff during the visit. Practitioners can choose alternative validated tools appropriate for their population or setting.

Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Score

Alcohol Misuse

Propose Actions/Treatment Considerations

Men: Score < 8

Women: Score < 4

Persons ≥ 65: Score < 4

Negative

Advise staying within recommended drinking limits: for general population, defined as <7 drinks/week or <3 drinks/occasion for women, and <14 drinks per week or <4 drinks/occasion for men. Recommend lower limits as medically indicated. Re-screen annually.

Men: Score ≥ 8

Women: Score ≥ 4

Pregnant Women: Score > 0

Persons ≥ 65: Score ≥ 4

Positive for alcohol misuse and possibly alcohol dependence

Conduct further assessment: Evaluate individual AUDIT questions to more specifically screen for risky versus harmful versus dependent drinking (see page 2 of this guide). Consider testing for alcohol dependence.

If patient is positive for alcohol misuse but not alcohol dependence consider brief face-to-face counseling intervention (reimbursed by new Medicare Procedure Code G0443) or referral.

If patient is positive for alcohol dependence recommend abstinence, negotiate a drinking goal, consider the need for medically managed withdrawal and medication for alcohol dependence, recommend mutual help group (screening plus counseling for alcohol dependence reimbursed by Medicare Procedure Codes G0396 or G0397) or refer to Specialist.