Alcohol Misuse Screening and Counseling Now Covered by Medicare In Primary Care Setting

December 5th, 2011

Effective October 14, 2011, Medicare is covering two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes) are available for primary care providers.  Payment for the service is approximately $16 for the screening and $24 for the 15 minutes behavioural counseling.  As with most preventive services,deductibles and coinsurance do not apply.

Medicare uses a definition of alcohol misuse which includes risky/hazardous and harmful drinking which place individuals at risk for future problems.

In the general adult population, risky or hazardous drinking 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.

Per MLN Matters Number MM7633:

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 four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:

  1. who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,
  2. who are competent and alert at the time that counseling is provided; and,
  3. whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

Each of the four behavioral counseling interventions must be consistent with the 5As approach that has been adopted by the USPSTF to describe such services:

  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 patient’s 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.

For the purposes of this covered service, the following provider specialty types may submit claims for G0442 and G0443:

  1. 01-General Practice
  2. 08-Family Practice
  3. 11-Internal Medicine
  4. 16-Obstetrics/Gynecology
  5. 37-Pediatric Medicine
  6. 38-Geriatric Medicine
  7. 42-Certified Nurse Midwife
  8. 50-Nurse Practitioner
  9. 89-Certified Clinical Nurse Specialist
  10. 97-Physician Assistant

For purposes of this covered service, the following place of service (POS) codes are applicable:

  1. 11-Physician’s Office
  2. 22-Outpatient Hospital
  3. 49-Independent Clinic
  4. 71-State or local public health clinic


Tags: Alcohol Misuse, Preventive Services


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