Covered and Noncovered Services : Screening, Brief Intervention, and Referral to Treatment Benefit

An Overview

Definition

The SBIRT benefit is covered for members enrolled in BadgerCare Plus and Wisconsin Medicaid. Members enrolled in an HMO must receive the services through the HMO. This benefit applies to members who are 10 years of age or older on the DOS. These services do not require PA and are not subject to copayment.

The purpose of the SBIRT benefit is to identify and assist members at risk for substance abuse problems. The benefit has two components:

• Screening for substance abuse problems
• Brief preventive substance abuse intervention for members identified as being at risk for having substance abuse disorders

The substance abuse screening and intervention services are designed to prevent members from developing a substance abuse disorder. These services are not intended to address tobacco abuse. These services are not intended to treat members diagnosed with a substance abuse disorder or to treat members already receiving substance abuse treatment services. Members identified through the screening and intervention process as needing more extensive or specialized treatment should be referred to an appropriate substance abuse program. A physician's prescription is not required for SBIRT services.

To be reimbursable, SBIRT services must be provided on a face-to-face basis (either in person or via simultaneous audio and video transmission).Telephone and internet-based communications with members are not covered.

Members who are pregnant are eligible for substance abuse screening and intervention services through a separate benefit designed specifically for pregnant women. ForwardHealth will not cover both benefits during the member's pregnancy. Providers are required to use either the benefit for pregnant women or the SBIRT benefit for the substance abuse screening and intervention services.

Substance Abuse Screening

Substance abuse screening is a method for identifying people who use alcohol or drugs in a way that puts them at risk for problems or injuries related to their substance use. Wisconsin Medicaid and BadgerCare Plus cover substance abuse screening in a wide variety of settings to increase the chance of identifying people at risk. Screening is also a part of primary prevention aimed at educating members about the health effects of using alcohol and other drugs.

Providers are required to use an evidence-based screening tool to identify members at risk for substance abuse problems. A few brief questions on substance use may be asked to identify those individuals likely to need a more in-depth screening. Those brief screening questions, however, do not meet the criteria for reimbursement for this benefit. The screening tool must demonstrate sufficient evidence that it is valid and reliable to identify individuals at risk for a substance abuse disorder and provide enough information to tailor an appropriate intervention to the identified level of substance use. The areas that must be covered include:

• The quantity and frequency of substance use
• Problems related to substance use
• Dependence symptoms
• Injection drug use

The screening tool should be simple enough to be administered by a wide range of health care professionals. It should also focus on the frequency and the quantity of substance use over a particular time frame (generally 1 to 12 months).

Below is a listing of evidence-based substance abuse screening tools that meet the criteria for reimbursement for this benefit. Providers may choose tools that are not included on the list as long as they meet the criteria above. In addition, providers must obtain prior approval from the Wisconsin DHS before using a tool that is not listed below. Contact DHS at DHSSBIRT@wisconsin.gov for additional information. The approved tools include the following:

• The AUDIT. This screen is a reliable tool for use to determine the level of alcohol use. The AUDIT screen is available through the WHO Web site.
• The DAST. This screening tool is a reliable tool to use to determine the level of drug use. The DAST screen is available through the Dr. Alan Tepp, Ph. D., website.
• The ASSIST. This screen is available through the WHO website.
• The CRAFFT screening tool developed by John Knight at the CeASAR. The CRAFFT screening tool is available through the CeASAR website. This screen is valid for use with children and adolescents.
• The POSIT. This screen is valid for use in adolescents in a medical setting. A POSIT PC tool is available through the POSIT PC website.

Providers may use more than one screening tool during the screening process when appropriate; however, there is no additional reimbursement for using more than one screening tool.

Substance Abuse Intervention

Brief substance abuse intervention services are covered for members who are identified through the use of an evidence-based screening tool as being at risk for substance abuse disorder(s). The purpose of the intervention is to motivate the member to decrease or abstain from alcohol consumption and/or drug use. Brief intervention may be a single session or multiple sessions using a motivational discussion that focuses on increasing insight and awareness regarding substance use and increasing motivation toward behavioral change. Brief intervention can also be used for those in need of more extensive levels of care, as a method of increasing motivation and acceptance of a referral to specialty substance abuse treatment.

Wisconsin Medicaid and BadgerCare Plus cover brief intervention services provided during the same visit as the screening or during a separate visit. The brief intervention is not covered for members who have not had a substance abuse screen.

Providers are required to use effective strategies for the counseling and intervention services although BadgerCare Plus and Wisconsin Medicaid are not endorsing a specific approach.

Examples of effective strategies for the intervention services include the following:

• The SBIRT protocols. The SBIRT protocols are available through the U.S. Department of Health and Human Services.
• "Helping Patients Who Drink Too Much," A Clinician's Guide, Updated 2005 Edition, available through the U.S. Department of Health and Human Services.

Coverage Limitations

Substance Abuse Screening

For members enrolled in BadgerCare Plus or Wisconsin Medicaid, the screening is limited to one unit of service per rolling 12 months. A unit of service is equivalent to the total amount of time required to administer the screening.

The screening is not considered part of the mental health and substance abuse services available under ForwardHealth. The screening is not counted towards any service limitations or PA thresholds for those services.

Substance Abuse Intervention

For members enrolled in BadgerCare Plus and Wisconsin Medicaid, the intervention services are limited to four hours per rolling 12 months. A unit of service is 15 minutes, so the four-hour limit is equal to 16 units of service.

Only one hour (up to four units of service) can be billed on one DOS. The intervention services may be provided on the same DOS or on a later DOS than the screening.

The intervention services are not considered part of the mental health and substance abuse services available under ForwardHealth and are not counted towards any service limitations or PA thresholds for those services.

Documentation Requirements

In addition to documenting the service provided, providers are required to keep a copy of the completed screening tool(s) in the member's medical record. Providers using electronic medical records should make a note of which screening tool was used if they do not have an electronic version of the tool, and note the member's responses to the screening questions. Providers are also required to retain documents concerning the provider's education, training, and supervision.

Refer to the Documentation chapter of the Provider Enrollment and Ongoing Responsibilities section of the appropriate Online Handbook for more information about additional documentation requirements.

Eligible Providers

Early detection of substance abuse problems is crucial to successfully treating members. It is also important for members to obtain referrals for follow-up care when appropriate. In order to accomplish these goals, BadgerCare Plus and Wisconsin Medicaid are allowing a wide range of Medicaid-enrolled providers to administer the SBIRT services.

The following table lists providers eligible to receive reimbursement for the screening and the substance abuse intervention services.

Providers are required to retain documents showing that staff providing substance abuse screening and intervention services meet the training, education, and supervision requirements.

Requirements for Licensed Individuals

Licensed health care professionals must complete the Wisconsin DHS-approved training to directly deliver the screening and intervention services. Training for licensed professionals must extend at least 4 hours and may be conducted in person or via the internet. DHS may exempt licensed professionals with expertise in the field of substance abuse screening and motivational enhancement or motivational interviewing on a case by case basis.

Providers should contact the DHS at DHSSBIRT@wisconsin.gov for more information about the required training or to find out if they can be exempted from the training requirements.

Requirements for Unlicensed Individuals

Unlicensed individuals may provide screening or brief intervention services if they meet all of the following criteria:

• Successfully complete at least 60 hours of training related to providing screening and brief intervention for alcohol and substance abuse (other than tobacco). This training includes the DHS-approved training to deliver the screening and intervention services. At least 30 hours of training must be conducted in person.
• Provide the screening and intervention services under the supervision of a licensed health care professional.
• Follow written or electronic protocols for evidence-based practice during the delivery of screening and intervention services. Protocols must be consistently followed, so the licensed health care professional must ensure that quality assurance procedures are in place for the written or electronic protocols.

Information is available for DOS before October 1, 2023.

Procedure Codes and Diagnosis Codes

The following tables list the HCPCS procedure codes and applicable diagnosis codes that providers are required to use when submitting claims for substance abuse screening and substance abuse intervention services under the SBIRT benefit.