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The ACMT Connection > Addiction Medicine Billing Pearls

Addiction Medicine Billing Pearls

Using time-based encounters in the toxicology clinic for buprenorphine-related visits. 

Timothy J. Wiegand, MD, FACMT1 & Tracey Loveland, CMBS2

  • Director of Toxicology at the University of Rochester Medicine, Rochester, NY
  • Certified Medical Billing Specialist, Special Projects Coordinator, Emergency Associates, Rochester, NY.

In the past few years an increasing number of medical toxicologists have obtained an X-waiver certification, which allows for the provider to prescribe buprenorphine to treat craving and withdrawal for individuals with an opioid use disorder. Some toxicologists are doing this in a ‘bridge’ clinic in order to see patients given buprenorphine in the Emergency Department or in the hospital setting in follow-up. Others have opened their toxicology clinic to provide treatment for patients with opioid, and other substance, use disorders. These types of visits are often performed using “time based” E & M (Evaluation & Management) services.   In order to bill time-based encounters over half of the total time of the visit needs to have been spent counseling.  This must be documented as such in the chart and the documentation must include what was discussed during the counseling.

My typical note for these visits includes the following type of documentation:

Medical Toxicology Clinic Visit

PMP # (New York ID confirmation that demonstrates I reviewed the PMP for this visit) copied here)

S: Patient seen for f/u related to buprenorphine visit. On a stable dose of 8/2 mg SL BID. No craving or w/d. Denies use no relapse no use opiates or other substances. Patient feels that the dose of Suboxone® is fine without any side effects. No interest in tapering. Discussed risk/benefit of continuing. Today’s visit included discussion on relapse prevention (continuing AA/NA and the new Heroin Anonymous meeting in our area), use of family support and exercise. UDS done and PMP reviewed (see above). No questions about the screens.

Additional patient specific information here.

O:

Vitals: HR, BP, RR

PE: observational PE

No mydriasis no rhinorrhea or tearing…

Pleasant and not confused…

Etc.…

Drug testing results:

UDS screen included norbup-cr levels 400’s ng/mg Cr neg illicit drugs and neg EtG.

COWS is 0

A/P: XX year-old M/F with opiate dep doing well on Suboxone 8/2 mg SL BID no indication to change dose no side effects no use continues to doing well.

-Suboxone 8/2 mg SL BID disp 56 f/u one month

-UDS and confirmations bup metabolite profile and Cr

-Istop (PMP) reviewed

-Smoking cessation counseling and med review

Patient seen on 8/19/2017 at 0830 x 25 min which included counseling related to relapse prevention and ongoing use of MAT.

CPT codes for existing patient visits include 99211 -5 (I typically use 99214 which is 25 minutes. A quick visit may be done in 15 minutes (99213) and a longer is 40 minutes (99215). There are other types of CPT codes for new patients, induction visits, medication administration (H0033). Sometimes additional codes can be added on to these visits if additional services are performed. The most common for my practice is smoking cessation encounters which include the 99406 or 99407 CPT codes depending on the time involved (> 3 min =99406 and > 11 min =99407). Our attestation for the smoking cessation is: (smart phrase for Epic .edsmoke =

Three plus minutes of smoking cessation counseling done. Patient co-morbidities include {insert comorbidities} Risks of smoking reviewed including possible lung disease (COPD, cancer) and cardiac disease. Options of cessation aides reviewed including nicotine patch, hypnosis, and possible prescription medications. Patient encouraged to follow-up with outpatient physician.