Wiki G0442 and G0444 supporting documentation

clegrand

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I have recently been asked to review some Medicare Wellness notes and I have seen that G0442 and G0444 have been added (on various occasions) to the encounter.

In examples of the G0442...the only thing I am seeing in the note is social history: drinks occasionally I am not seeing how that is enough to bill for alcohol misuse screening.

In examples of G0444....some of the things that I am seeing are that a PHQ-2 was utilized and score was 0. That tool is provided by the MA and results entered by them for the provider to review. Is that truly enough to bill for a depression screen?

Any insight you could provide would be greatly appreciated! Thanks
 
No, the information documented is not enough to support those codes. These are timed codes, meaning the time spent on administering the screening must be documented. In addition, you don't mention if these codes are being billed together, but as of 1/1/2020, CMS considers G0442 to be included (column 2 code) in G0444, so a modifier is not allowed.
 
Supercoder/AAPC Coder says for G0442:
A provider screens a patient for alcohol misuse. He provides this service to an individual who is currently experiencing physical, social, and psychological harm from alcohol use, but may not have a dependence problem. The provider offering the service is typically a primary care clinician in a primary care setting. The patient receives the service in the provider's office, outpatient hospital, or independent clinic. The service is time based and the provider will take 15 minutes for the interaction with the patient.
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this is a time based code, so, the provider must document at least 8 minutes for the service in order to qualify for G0442.
 
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