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- •For commercial insurers (Level 1 HCPCS/CPT codes) and Medicare codes (“G” codes), the minimum time documentation for SBIRT delivery is 15 min, delivered by licensed independent practitioners who are not psychiatric or mental health specialists (LIP; e.g., primary care MDs, nurse practitioners, physician assistants).
- ○There is a mismatch between SBIRT and the billing code criteria for reimbursement of SBIRT. An SBIRT procedure takes 5 to 15 min to complete, but Level 1 HCPCS/CPT codes require clinical documentation of an SBIRT procedure lasting at least 15 min for reimbursement by private payers and Medicare.
- ○Level 1 HCPCS/CPT codes for SBIRT allow only reimbursement for primary care LIPs. Registered nurses are not included as LIPs, thus the largest component of the frontline primary care health workforce is eliminated from reimbursement for SBIRT. SBIRT is designed and has been studied however, as being administered by generic nonpsychiatric specialist providers such as generalist, registered nurses. The requirement that only primary care LIPs administer SBIRT to bill for the procedure is neither cost nor time effective for most practice settings.
- ○Not all commercial payers reimburse nonphysician LIPs (e.g., nurse practitioners, nurse midwives, physician assistants) for SBIRT.
- •Medicaid uses either HCPCS Level 1 and/or Level 2 codes for reimbursement.
- ○Only 23 states have assigned reimbursement to SBIRT HCPCS Level 1 or Level 2 codes.
- ○Under Level 1 code, no minimum time exists for screening, but only nine states currently offer reimbursement using this code.
- ○Thirteen states have activated either HCPCS Level 1 or Level 2 codes for Medicaid but have not assigned any reimbursement to the codes.
- ○Some nonphysician clinical psychologists in primary care settings may use Health Behavior Assessment and Intervention (HBAI) codes that require documentation of at least 15 min of SBIRT procedure for Medicaid reimbursement in 23 states.
- ○There are “same-day restrictions” on HBAI codes in some states. Thus, authorized HBAI providers cannot bill for SBIRT on the same day that a different provider bills for other health service(s). This policy discourages providers from adding SBIRT to their current screening batteries.
Nursing Can Be Part of the Solution
- •Allow reimbursement to agencies for SBIRT delivered by registered nurses. Reimburse the facilities or institutions for nurse-delivered SBIRT using the appropriate additional CPT codes versus including this in the evaluation and management CPT code reimbursement.
- •Include primary care advanced practice registered nurses and all registered nurses as qualified for direct SBIRT reimbursement by private and public payers.
- •Allow same-day billing for SBIRT screens by nonphysician clinicians using HBAI codes across all 50 states.
- •Alter the current billing code requirements to accurately reflect the time required to administer the SBIRT intervention.
- ○Set the billing code criteria to 5 to 15 min at a maximum for SBIRT administration and allow use of “incident to” billing codes.
- •The states (13) using at least one HCPCS SBIRT code should assign reimbursement value to the codes. States should be encouraged to set a reimbursement amount for the SBIRT codes reflective of the time and expertise required for SBIRT.
- •States that have not activated any HCPCS SBIRT codes for Medicaid reimbursement should activate codes and assign appropriate reimbursement values.
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Corresponding author: Cheryl G. Sullivan, American Academy of Nursing, 1000 Vermont Avenue, NW, Suite 910, Washington, DC 20005. E-mail address: [email protected] (C.G. Sullivan).