How To Use CPT Code 99408

CPT 99408 refers to alcohol and/or substance abuse structured screening and brief intervention services, taking 15 to 30 minutes. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99408 procedures.

1. What is CPT 99408?

CPT 99408 is a medical billing code used to report alcohol and/or substance abuse structured screening and brief intervention services provided by healthcare professionals. These services are aimed at identifying patients with potential alcohol or substance abuse issues and providing them with appropriate interventions to address their condition. The code is used to bill for services that take between 15 to 30 minutes to complete.

2. 99408 CPT code description

The official description of CPT code 99408 is: “Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes.”

3. Procedure

1. The healthcare provider conducts a structured screening using a validated instrument, such as the Alcohol Use Disorder Identification Test (AUDIT) or the Drug Abuse Screening Test (DAST).
2. The provider evaluates the screening results to determine if the patient requires a brief intervention.
3. If necessary, the provider performs a brief intervention, discussing the negative consequences of substance abuse, the patient’s usage patterns, and potential steps for behavior change.
4. The provider documents the screening instrument used, the results, and the nature of the intervention provided.

4. Qualifying circumstances

Patients eligible to receive CPT 99408 services are those who have been identified as potentially having alcohol or substance abuse issues through the use of a validated screening instrument. The provider must determine that a brief intervention is necessary based on the screening results. Services must be provided within a 15 to 30-minute time frame to qualify for billing under CPT 99408.

5. When to use CPT code 99408

It is appropriate to bill CPT 99408 when a healthcare provider has conducted a structured screening for alcohol or substance abuse, determined that a brief intervention is necessary, and provided the intervention within a 15 to 30-minute time frame. If the screening indicates that the patient does not require an intervention, the screening should be included in the selection of the E/M or preventive service code instead.

6. Documentation requirements

To support a claim for CPT 99408, the following information must be documented:

• The validated screening instrument used (e.g., AUDIT or DAST)
• The results of the screening
• The determination that a brief intervention is necessary
• The nature of the intervention provided
• The duration of the screening and intervention (15 to 30 minutes)

7. Billing guidelines

When billing for CPT 99408, ensure that the services provided meet the criteria outlined in the code description, including the use of a validated screening instrument, the determination of the need for a brief intervention, and the provision of the intervention within the specified time frame. For Medicare patients, consider using G0396 or G0397 instead of CPT 99408 or 99409. Do not report services lasting less than 15 minutes with CPT 99408.

8. Historical information

CPT 99408 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates to the code since its addition.

9. Similar codes to CPT 99408

Five similar codes to CPT 99408 include:

• CPT 99409: This code is used for alcohol and/or substance abuse structured screening and brief intervention services lasting more than 30 minutes.
• G0396: This code is used for Medicare patients receiving alcohol and/or substance abuse screening and brief intervention services lasting 15 to 30 minutes.
• G0397: This code is used for Medicare patients receiving alcohol and/or substance abuse screening and brief intervention services lasting more than 30 minutes.
• CPT 96127: This code is used for brief emotional/behavioral assessment with scoring and documentation.
• CPT 96160: This code is used for patient-focused health risk assessment with scoring and documentation.

10. Examples

Here are 10 detailed examples of CPT 99408 procedures:

1. A primary care physician screens a patient using the AUDIT during a routine checkup and determines that a brief intervention is necessary. The physician spends 20 minutes discussing the patient’s alcohol consumption and potential steps for behavior change.
2. A nurse practitioner screens a patient using the DAST during a preventive care visit and determines that a brief intervention is necessary. The nurse practitioner spends 25 minutes discussing the patient’s drug use and potential steps for behavior change.
3. A psychiatrist screens a patient using the AUDIT during a follow-up visit for depression treatment and determines that a brief intervention is necessary. The psychiatrist spends 15 minutes discussing the patient’s alcohol consumption and potential steps for behavior change.
4. A primary care physician screens a patient using the DAST during a routine checkup and determines that a brief intervention is necessary. The physician spends 30 minutes discussing the patient’s drug use and potential steps for behavior change.
5. A nurse practitioner screens a patient using the AUDIT during a preventive care visit and determines that a brief intervention is necessary. The nurse practitioner spends 20 minutes discussing the patient’s alcohol consumption and potential steps for behavior change.
6. A psychiatrist screens a patient using the DAST during a follow-up visit for anxiety treatment and determines that a brief intervention is necessary. The psychiatrist spends 25 minutes discussing the patient’s drug use and potential steps for behavior change.
7. A primary care physician screens a patient using the AUDIT during a routine checkup and determines that a brief intervention is necessary. The physician spends 15 minutes discussing the patient’s alcohol consumption and potential steps for behavior change.
8. A nurse practitioner screens a patient using the DAST during a preventive care visit and determines that a brief intervention is necessary. The nurse practitioner spends 30 minutes discussing the patient’s drug use and potential steps for behavior change.
9. A psychiatrist screens a patient using the AUDIT during a follow-up visit for bipolar disorder treatment and determines that a brief intervention is necessary. The psychiatrist spends 20 minutes discussing the patient’s alcohol consumption and potential steps for behavior change.
10. A primary care physician screens a patient using the DAST during a routine checkup and determines that a brief intervention is necessary. The physician spends 25 minutes discussing the patient’s drug use and potential steps for behavior change.