New CPT codes promote drug abuse screening.

Two new health care codes for substance abuse screening and brief intervention set to take effect Jan. 1, 2008, will "strengthen the doctor-patient relationship and incorporate a powerful preventive public health resource in America's health care system," according to the White House Office of National Drug Control Policy. But the medical community appears to be taking a wait-and-see approach.

Reimbursement for the new Current Procedural Terminology (CPT) codes (99408 and 99409) is a key concern among physicians informally polled about these new additions. The existence of codes does not ensure payment for the codes, and it is unclear whether the codes will be accepted by insurers.

"The key issue is not whether there are new CPT codes, but whether insurers and Medicare will pay for them, and could they be added to other CPT codes at the same visit," said Dr. David Spiegel, Willson professor and associate chair in the department of psychiatry and behavioral sciences at Stanford (Calif.) University.

The potential value of these services for patients is another concern; some physicians question the value of "brief interventions" for substance use.

"My immediate response is that the government is putting the cart before the horse insofar as years of inadequate or no funding for drug treatment have left limited resources for physicians to refer to if patients screen positive," said Dr. Jon O. Ebbert, an internist at the Mayo Clinic, Rochester, Minn. "Furthermore, I have concerns about the utility of 'brief interventions' for substance use and whether physicians who bill for these are adequately trained to deliver them."

Similarly, Dr. Lee H. Beecher, a psychiatrist in private practice in St. Louis Park, Minn., said it would be encouraging to see evidence that adding such codes will change clinical practice.

"We already have too many CPT codes in medicine and fewer for mental health services, because our procedures are described as evaluation, psychotherapy, pharmacotherapy, [electroconvulsive therapy], and inpatient care management," said Dr. Beecher, also of the department of psychiatry at the University of Minnesota, Minneapolis. "Psychiatrists sell time to the government. We are paid the same with no account of the patient's responses. This drives the common denominator to its lowest level and encourages 'upcoding' of work [intensity]."

Dr. Beecher said psychiatrists are currently being paid a low rate by Medicare for patient encounter time, so specifying the content of clinical interventions "will lead to the frustration of obsessive paperwork and whip cracking from clinic managers for 'productivity.'"

The new codes (99408 for interactions of 15-30 minutes, and 99409 for interactions over 30 minutes) were issued by the American Medical Association in October. According to the White House statement, they will enable efficient reporting of screening services for drug and alcohol abuse (see box), and increase the likelihood of appropriate interventions for those in need. Because similar codes for tobacco use screening and intervention previously were instituted, tobacco use screening and cessation counseling are excluded in these codes.

The codes provide medical professionals a means to "communicate concisely and reliably with colleagues, patients, and insurers about screening for substance use and appropriate interventions," according to the statement.

The American College of Physicians, which did not create the codes but was involved in evaluating and developing them, will encourage private insurers to reimburse for the codes, Brian Whitman, a senior analyst for regulatory and insurer affairs with the ACP said in an interview.

If physicians are reimbursed, use of the codes among members will be promoted, Mr. Whitman said, noting that the new codes are important because unlike tobacco use screening and interventions, substance and alcohol use screening is less common and typically more time-consuming. For example, substance and alcohol use screening can require up to 15 minutes for the structured screening, compared with as few as 3 minutes for typical tobacco use screening in a typical office visit.

Substance use screening "is a bit more specialized," he said. "But to the extent that payers will accept them--and we hope they do-we would encourage members to use them," he said of the codes.

Similarly, the American Academy of Family Physicians will be "watching closely to see what payers will do," Cindy Hughes, a coding and compliance specialist with the AAFP, said in an interview.

The AAFP's stance on the codes largely will depend on whether payers accept the codes and on the value that is assigned, Ms. Hughes said.

Nonetheless, some see potential benefits with the use of these codes.

"They implicitly acknowledge that screening and short intervention for substance abuse are practical and effective," said Dr. Rodrigo A. Munoz, of the University of California, San Diego. "This challenges most health professionals to give utmost attention to this problem."

Additionally, the codes are a reminder that substance abuse problems are "common, costly, diagnosable, treatable, and often associated with other diagnoses in many medical specialties," Dr. Munoz said.

Although Dr. William E. Golden, professor of medicine and public health at the University of Arkansas, Little Rock, said that he agrees with Dr. Ebbert that referral options are limited for those who screen positive, he noted that there is potential value in screening because "understanding patients' habits can alter primary care prescribing even if there are limited options for effective interventions."

BY SHARON WORCESTER

Southeast Bureau

Drug Screening Sample Questions

The Drug Abuse Screening Test is a tool that physicians can use to screen for drug abuse during office visits. Sample questions from the DAST include the following, according to the Office of National Drug Control Policy:

* Can you get through the week without using drugs?

* Are you always able to stop using drugs when you want to?

* Do you ever feel bad or guilty about your drug use?

* Have you neglected your family because of your use of drugs?

* Have you been in trouble at work because of your use of drugs?

* Have you engaged in illegal activities in order to obtain drugs?

* Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

* Have you ever had medical problems as a result of your drug use (for example, memory loss, hepatitis, convulsions, bleeding, and so on)?