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New Medicare Preventive Care Offerings
JNP
New Medicare Preventive Care Offerings The Centers for Medicare & Medicaid Services (CMS) added several services to their preventive care offerings at the end of 2011. Alcohol screening, depression screening, and intensive behavioral therapy for cardiovascular disease prevention and for obesity are all new screenings. This column covers the first 2 topics; the last topic will be discussed in the next issue.
According to section 1861 of the Social Security Act, CMS may add coverage of additional preventive services through the National Coverage Determination (NCD) process if all of the following criteria are met. They must be: 1. Reasonable and necessary for the prevention or early detection of illness or disability. 2. Recommended with a grade of A or B by the US Preventive Services Task Force (USPSTF). 3. Appropriate for individuals entitled to benefits under Part A or enrolled under Part B of the Medicare Program. CMS reviewed the USPSTF’s “B” recommendation and supporting evidence for “Screening and
DECODING CODES Jan DiSantostefano, NP Behavioral Counseling Intervention in Primary Care to Reduce Alcohol Misuse” preventive services and determined that all 3 criteria were met. According to the USPSTF (2004), alcohol misuse includes risky/hazardous and harmful drinking that place individuals at risk for future problems. In the general adult population, this is defined as > 7 drinks per week or > 3 drinks per occasion for women and > 14 drinks per week or > 4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing physical, social, or psychological harm from alcohol use but who do not meet criteria for dependence. 410
The Journal for Nurse Practitioners - JNP
Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to 4 brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women: • Who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least 3 of the following: tolerance; withdrawal symptoms; impaired control; preoccupation with acquisition or use; persistent desire or unsuccessful efforts to quit; sustains social, occupational, or recreational disability; use continues despite adverse consequences) • Who are competent and alert at the time that counseling is provided • Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting Each of the 4 behavioral counseling interventions must be consistent with the 5-A approach adopted by the USPSTF to describe such services: • Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods. • Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. • Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior. • Assist: Using behavior change techniques (self-help or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental Volume 8, Issue 5, May 2012
supports for behavior change, supplemented with adjunctive medical treatments when appropriate. • 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. Two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief Face-to-Face Behavioral Counseling for Alcohol Misuse, 15 minutes), took effect October 14, 2011. Medicare specifies what provider types may submit claims for this service and what places of service are allowed. Revised from http://www.cms.gov/MLNMatters Articles/Downloads/MM7633.pdf. Among persons older than 65 years, 1 in 6 suffers from depression. Depression in older adults is estimated to occur in 25% of those with chronic illness. Other stressful events, such as the loss of friends and loved ones, are also risk factors. Older adults have the highest risk of suicide of all age groups. These patients are important in the primary care setting because 50%-75% of older adults who commit suicide saw their medical provider during the prior month for general medical care, and 39% were seen during the week of their death. Screening for depression in adults is recommended with a grade of B by the USPSTF. Thus, effective October 14, 2011, Medicare covers annual screening for adults for depression in a primary care setting that has staff-assisted depression care supports in place to ensure accurate diagnosis, effective treatment, and follow-up. A primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospice are not considered primary care settings under this definition. www.npjournal.org
Effective for claims with dates of service on and after April 2, 2012, contractors shall pay for G0444 (Annual Depression Screening, 15 minutes). At a minimum level, staff-assisted depression care supports consist of clinical staff (eg, nurse, physician assistant) in the primary care office who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment. More comprehensive care supports include a case manager working with the primary care physician; planned collaborative care between the primary care provider and mental health clinicians; patient education and support for patient self-management; plus attention to patient preferences regarding counseling, medications, and referral to mental health professionals, with or without continuing involvement by the patient’s primary care physician. Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medication), or other interventions. Self-help materials, telephone calls, and Web-based counseling are not separately reimbursable by Medicare. Screening for depression is not covered when performed more than once in a 12-month period. Eleven full months must elapse after the month in which the last annual depression screening took place. Medicare coinsurance and Part B deductible are waived for this preventive service. Revised from http://www.cms.gov/MLNMatters Articles/Downloads/MM7637.pdf. Jan DiSantostefano, NP, is a family and women’s health nurse practitioner at the SAS Institute, Inc., in Cary, NC. She can be reached at [email protected]. 1555-4155/121/$ see front matter © 2012 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2012.01.022
The Journal for Nurse Practitioners - JNP
411
New Medicare Preventive Care Offerings The Centers for Medicare & Medicaid Services (CMS) added several services to their preventive care offerings at the end of 2011. Alcohol screening, depression screening, and intensive behavioral therapy for cardiovascular disease prevention and for obesity are all new screenings. This column covers the first 2 topics; the last topic will be discussed in the next issue.
According to section 1861 of the Social Security Act, CMS may add coverage of additional preventive services through the National Coverage Determination (NCD) process if all of the following criteria are met. They must be: 1. Reasonable and necessary for the prevention or early detection of illness or disability. 2. Recommended with a grade of A or B by the US Preventive Services Task Force (USPSTF). 3. Appropriate for individuals entitled to benefits under Part A or enrolled under Part B of the Medicare Program. CMS reviewed the USPSTF’s “B” recommendation and supporting evidence for “Screening and
DECODING CODES Jan DiSantostefano, NP Behavioral Counseling Intervention in Primary Care to Reduce Alcohol Misuse” preventive services and determined that all 3 criteria were met. According to the USPSTF (2004), alcohol misuse includes risky/hazardous and harmful drinking that place individuals at risk for future problems. In the general adult population, this is defined as > 7 drinks per week or > 3 drinks per occasion for women and > 14 drinks per week or > 4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing physical, social, or psychological harm from alcohol use but who do not meet criteria for dependence. 410
The Journal for Nurse Practitioners - JNP
Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to 4 brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women: • Who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least 3 of the following: tolerance; withdrawal symptoms; impaired control; preoccupation with acquisition or use; persistent desire or unsuccessful efforts to quit; sustains social, occupational, or recreational disability; use continues despite adverse consequences) • Who are competent and alert at the time that counseling is provided • Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting Each of the 4 behavioral counseling interventions must be consistent with the 5-A approach adopted by the USPSTF to describe such services: • Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods. • Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits. • Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior. • Assist: Using behavior change techniques (self-help or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental Volume 8, Issue 5, May 2012
supports for behavior change, supplemented with adjunctive medical treatments when appropriate. • 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. Two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief Face-to-Face Behavioral Counseling for Alcohol Misuse, 15 minutes), took effect October 14, 2011. Medicare specifies what provider types may submit claims for this service and what places of service are allowed. Revised from http://www.cms.gov/MLNMatters Articles/Downloads/MM7633.pdf. Among persons older than 65 years, 1 in 6 suffers from depression. Depression in older adults is estimated to occur in 25% of those with chronic illness. Other stressful events, such as the loss of friends and loved ones, are also risk factors. Older adults have the highest risk of suicide of all age groups. These patients are important in the primary care setting because 50%-75% of older adults who commit suicide saw their medical provider during the prior month for general medical care, and 39% were seen during the week of their death. Screening for depression in adults is recommended with a grade of B by the USPSTF. Thus, effective October 14, 2011, Medicare covers annual screening for adults for depression in a primary care setting that has staff-assisted depression care supports in place to ensure accurate diagnosis, effective treatment, and follow-up. A primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospice are not considered primary care settings under this definition. www.npjournal.org
Effective for claims with dates of service on and after April 2, 2012, contractors shall pay for G0444 (Annual Depression Screening, 15 minutes). At a minimum level, staff-assisted depression care supports consist of clinical staff (eg, nurse, physician assistant) in the primary care office who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment. More comprehensive care supports include a case manager working with the primary care physician; planned collaborative care between the primary care provider and mental health clinicians; patient education and support for patient self-management; plus attention to patient preferences regarding counseling, medications, and referral to mental health professionals, with or without continuing involvement by the patient’s primary care physician. Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medication), or other interventions. Self-help materials, telephone calls, and Web-based counseling are not separately reimbursable by Medicare. Screening for depression is not covered when performed more than once in a 12-month period. Eleven full months must elapse after the month in which the last annual depression screening took place. Medicare coinsurance and Part B deductible are waived for this preventive service. Revised from http://www.cms.gov/MLNMatters Articles/Downloads/MM7637.pdf. Jan DiSantostefano, NP, is a family and women’s health nurse practitioner at the SAS Institute, Inc., in Cary, NC. She can be reached at [email protected]. 1555-4155/121/$ see front matter © 2012 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2012.01.022
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