CurrentCenCal HealthPolicy N/A

Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

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This policy governs annual alcohol misuse screening, behavioral counseling, and referral processes for CenCal Health members age 18 and older in primary care. It also addresses referrals for alcohol use disorder or co-occurring mental health needs, documentation, billing, and care coordination.

Policy Summary

PayerCenCal Health

PolicyAlcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2018

Next Review DateN/A

Key ActionScreen adult members age 18 and older for alcohol misuse at least annually and document the screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Eligible member age

1 annuallyRoutine screening

1–3 annuallyCounseling interventions

G0442 / G0443Billing codes

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CurrentCenCal HealthPolicy N/A

Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

Customize your policy alerts

Sign up for all cencalhealth policy alerts

Know when cencalhealth releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerCenCal Health

PolicyAlcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2018

Next Review DateN/A

Key ActionScreen adult members age 18 and older for alcohol misuse at least annually and document the screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Eligible member age

1 annuallyRoutine screening

1–3 annuallyCounseling interventions

G0442 / G0443Billing codes

Covered Screening, Counseling, and Referral Services

Routine alcohol misuse screening

Covered when all of the following are met:

Annual alcohol misuse screening: The member is age 18 or older; the screening is provided by a primary care provider; and the screening is performed at least annually as part of routine care.1 screening per year

Additional screening may be provided when medically necessary.

Validated screening tools

Use one validated screening approach:

Validated screening tool

The provider uses the Alcohol Use Disorders Identification Test (AUDIT).
The provider uses the abbreviated AUDIT-Consumption (AUDIT-C).
The provider uses a single-question screening approach, such as asking how many times in the past year the member consumed 4 or more drinks in a day for women and adults older than 65 years, or 5 or more drinks in a day for men.

Brief behavioral counseling

Covered when risky or hazardous drinking is identified:

Behavioral counseling intervention: The member is identified during screening as engaging in risky or hazardous drinking, and the member is offered brief behavioral counseling intervention.At least 1 and up to 3 interventions per year

Interventions may include cognitive behavioral strategies, action plans, drinking diaries, stress management, or problem solving, and may be delivered face-to-face, in writing, by computer or web, or by telephone.

Alcohol use disorder referral

Referral required when either condition is present:

Referral to alcohol use disorder services

Upon primary care screening and evaluation, the member meets criteria for an alcohol use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Upon primary care screening and evaluation, the diagnosis is uncertain.

Co-occurring mental health needs

Referral destination depends on functional impairment:

Mental health or dual diagnosis referral

The member has risky alcohol use or alcohol use in early remission, and mental health symptoms cause mild to moderate impairment in the member's life.
Refer to either an on-site mental health provider or CenCal MHBO for mental health services.
The member has risky alcohol use and mental health symptoms cause moderate to severe functional impairment.
Refer to County Behavioral Health for treatment services.

Professional fees for alcohol treatment

Covered within the provider's scope of practice:

Primary care treatment visits: CenCal reimburses professional fees for visits during which alcohol treatment is provided when the treatment is within the provider's scope of practice.Within provider scope of practice

Examples include prescribing medication for withdrawal symptoms or medication supporting addiction recovery by providers with the necessary waiver.

Billing Codes and Service Parameters

Alcohol misuse screeningHCPCSCovered

G0442

Annual alcohol misuse screening, 15 minutes

Behavioral counseling interventionsHCPCSCovered

G0443

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

Adult Screening Age

Minimum eligible age18 years of age and older

Eligible membersAdult members

Screening settingPrimary care

Routine Screening Frequency

Required frequency1 alcohol misuse screening per year

Additional screeningsProvided when medically necessary

Documentation

Documentation, Authorization, and Care Coordination

Documentation Required

Document Medical Necessity for Additional Screening

PCPs must provide one alcohol misuse screening annually for adult members age 18 and older. Additional screenings must be provided when medically necessary, including additional screening benefits for members ages 18–21 under EPSDT; the member’s PCP or primary care team must document medical necessity.

Use a validated screening tool: AUDIT, AUDIT-C, or a single-question screen.
Document the medical necessity supporting any screening beyond the annual benefit.
Members ages 18–21 may receive additional screening under EPSDT.

Prior Authorization

Authorization Required for Additional Counseling

Members identified through screening as engaging in risky or hazardous drinking must be offered brief behavioral counseling interventions. Members are entitled to at least one and up to three interventions per year; additional interventions require authorization when medically necessary, with medical necessity documented by the member’s primary healthcare provider.

Alcohol Misuse Screening Context

Alcohol misuse encompasses a spectrum of behaviors, including risky or hazardous drinking, and may progress to alcohol use disorder. CenCal Health requires primary care providers to screen members 18 years of age and older as part of routine care and to offer brief behavioral counseling when screening identifies risky or hazardous drinking.

Members who meet DSM criteria for alcohol use disorder or whose diagnosis is uncertain must be referred for county alcohol and substance use disorder treatment services. When alcohol use co-occurs with mental health symptoms, the referral destination is based on the degree of functional impairment, ranging from an on-site mental health provider or CenCal MHBO for mild-to-moderate impairment to County Behavioral Health for moderate-to-severe impairment.

Key Terms

Alcohol Misuse

DefinitionA spectrum of behaviors, including risky or hazardous alcohol use

Risky or hazardous useDrinking more than the recommended daily, weekly, or per-occasion quantity of alcohol

Health consequenceThis pattern of drinking results in increased risk for adverse health consequences

Alcohol Use Disorder

DefinitionA condition in which a patient meets the criteria in the Diagnostic and Statistical Manual for a substance use disorder resulting from alcohol use

Clinical descriptionA chronic relapsing brain disease

Characteristics

Policy Summary

PayerCenCal Health

PolicyAlcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2018

Next Review DateN/A

Key ActionScreen adult members age 18 and older for alcohol misuse at least annually and document the screening.

SourceLink

On This Page

Medical necessity for additional screenings must be documented by the member's primary care provider or primary care team

Behavioral Counseling Frequency

Annual minimumAt least 1 intervention per year

Annual maximumUp to a maximum of 3 interventions per year

Beyond the maximumAdditional interventions must be authorized when medically necessary, with medical necessity documented by the member's primary healthcare provider

Risky or Hazardous Use Example for Men

Daily exampleMore than 4 drinks on any day for men

Weekly example14 drinks per week for men

Clinical significanceThese amounts are examples of risky or hazardous alcohol use associated with increased risk for adverse health consequences

Risky or Hazardous Use Example for Women

Daily exampleMore than 3 drinks on any day for women

Weekly example7 drinks per week for women

Clinical significanceThese amounts are examples of risky or hazardous alcohol use associated with increased risk for adverse health consequences

Obtain authorization before providing behavioral counseling interventions beyond the maximum of three per year.
Document medical necessity for each additional intervention.
Interventions may include action plans, drinking diaries, stress management, problem solving, written materials, web-based programs, or telephone counseling.

Documentation Required

Document Screening and Obtain Prior Records

PCPs must maintain documentation of each member’s alcohol misuse screening. When a member transfers to another PCP, the receiving PCP must obtain prior medical records, including records of preventive services; if no screening documentation is found, the new PCP must provide and document an alcohol misuse screening.

Maintain screening records in the member’s medical record.
Obtain prior preventive-service records during transfer of care.
Provide and document screening when prior documentation is unavailable.

Documentation Required

PCP Documentation of Screening Necessity

The member’s PCP or primary care team is responsible for documenting medical necessity when providing alcohol misuse screening beyond the annual benefit. This documentation supports additional screening for adults and applicable EPSDT screening for members ages 18–21.

Identify the responsible PCP or primary care team.
Record the clinical rationale for additional screening.
Include documentation in the member’s medical record.

Documentation Required

Primary Provider Documentation of Counseling Necessity

The member’s primary healthcare provider must document medical necessity for behavioral counseling interventions provided beyond the covered annual range of one to three interventions. Additional interventions must be authorized when medically necessary.

Document the clinical rationale for additional counseling.
Ensure the documentation is completed by the primary healthcare provider.
Obtain authorization for counseling beyond three interventions per year.

Documentation Required

Obtain Consent for Coordinated Care

While a member receives alcohol treatment services, the primary healthcare provider continues to provide basic case management. Obtain the member’s written consent to allow information sharing between the primary healthcare provider and the substance use disorder treatment provider so care can be integrated and coordinated.

Obtain written member consent before sharing information.
Coordinate information exchange between the primary healthcare provider and the substance use disorder treatment provider.
Maintain the consent and related care-coordination documentation in the member’s record.

Compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using

Behavioral Counseling Interventions for Alcohol Misuse

DefinitionActivities delivered by primary care clinicians and related health care staff to assist patients in adopting, changing, or maintaining behaviors proven to affect health outcomes and health status

Alcohol-related focusIncluding appropriate alcohol use

Delivery personnelPrimary care clinicians and related health care staff

Drug Medi-Cal Organized Delivery System (DMC-ODS)

DefinitionA continuum of care modeled after the American Society of Addiction Medicine criteria for substance use disorder treatment services

Medi-Cal benefitAvailable to individuals who meet the medical necessity criteria for substance abuse services and reside in Santa Barbara or San Luis Obispo County

Service managementCounty Departments of Behavioral Health Services are responsible for management of DMC-ODS services