Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

A. General

Based upon authority to cover “additional preventive services” for Medicare beneficiaries if certain statutory requirements are met, the Centers for Medicare & Medicaid Services (CMS) initiated a new national coverage analysis on annual screening and brief behavioral counseling in primary care to reduce alcohol misuse in adults, including pregnant women. Annual screening and behavioral counseling for alcohol misuse in adults is recommended with a grade of B by the U.S. Preventive Services Task Force (USPSTF) and is appropriate for individuals entitled to benefits under Part A and Part B.

CMS will cover annual alcohol screening and up to four, brief face-to-face behavioral counseling in primary care settings to reduce alcohol misuse. CMS does not identify specific alcohol misuse screening tools. Rather, the decision to use a specific tool is at the discretion of the clinician in the primary care setting. Various screening tools are available for screening for alcohol misuse.

B. Nationally Covered Indications

Effective for claims with dates of service on or after October 14, 2011, CMS will 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:

• 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
• Who are competent and alert at the time that counseling is provided; and,
• Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

Each of the behavioral counseling interventions should be consistent with the 5A’s approach that has been adopted by the USPSTF to describe such services. They are:

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 policy, 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 hospices are not considered primary care settings under this definition.

For the purposes of this policy a “primary care physician” and “primary care practitioner” are to be defined based on two existing sections of the Social Security Act, §1833(u)(6), §1833(x)(2)(A)(i)(I) and §1833(x)(2)(A)(i)(II):

§1833(u)
(6)Physician Defined.—For purposes of this paragraph, the term “physician” means a physician described in section 1861(r)(1) and the term “primary care physician” means a physician who is identified in the available data as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.

§1833(x)(2)(A)(i)
(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or (II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5)).

C. Nationally Non-Covered Indications

1. Alcohol screening is non-covered when performed more than one time in a 12-month period.
2. Brief face-to-face behavioral counseling interventions are non-covered when performed more than once a day; that is, two counseling interventions on the same day are non-covered.
3. Brief face-to-face behavioral counseling interventions are non-covered when performed more than four times in a 12-month period.

D. Other

Medicare coinsurance and Part B deductible are waived for this preventive service.

(This NCD last reviewed October 2011.)

11/2011 - Effective with dates of service on and after October 14, 2011, CMS will cover annual alcohol screening, and for those that screen positive, up to 4, brief, face-to-face behavioral counseling interventions annually for Medicare beneficiaries, including pregnant women. This revision [to the Medicare National Coverage Determinations Manual] is a national coverage determination (NCD). NCDs are binding on all carriers, fiscal intermediaries,[contractors with the Federal government that review and/or adjudicate claims, determinations, and/or decisions], quality improvement organizations, qualified independent contractors, the Medicare appeals council, and administrative law judges (ALJs) (see 42 CFR section 405.1060(a)(4) (2005)). An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.) Effective date 10/14/2011. Implementation date 12/27/2011. (TN 138) (CR7633)