Preventive Services

Preventive Services Guide


Alcohol Misuse and Counseling

Table of Contents

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Alcohol Misuse and Counseling

The USPSTF recommended statement definitions:

  • Risky, hazardous, or harmful drinking which places an individual at risk for future problems with alcohol consumption. Alcohol consumption becomes hazardous or risky when consuming:
    • greater than seven drinks per week, or greater than three drinks per occasion for women and persons 65 years and older, and
    • greater than 14 drinks per week, or greater than four drinks per occasion for men.

Alcohol dependence is defined as having at least three of the following:

  • Tolerance
  • Withdrawal symptoms
  • Impaired control
  • Preoccupations with acquisition and/or use
  • Persistent desire or unsuccessful efforts to quit
  • Sustained social, occupational or recreational disability
  • Continuous use despite adverse consequences

Harmful drinking includes physical, social or psychological harm from alcohol use, but does not meet criteria for dependence.

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Two-Part Benefit

  • Annual screening, all beneficiaries
    • G0442: Annual alcohol misuse screening, 15 minutes
      • Annually
  • Behavioral counseling intervention, covered when criteria met
    • G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
      • For those who screen positive, covered four times per year
    • Covered when patient screened positive for alcohol misuse, but not alcohol dependence
    • Each behavioral counseling session intervention must be consistent with the five “A” approach adopted by the USPSTF; assess, advise, agree, assist, arrange
      • Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods
      • Advise: Give clear, specific and personalized behavior change advice, including information about personal health harms and benefits
      • Agree: Collaboratively select appropriate treatment goals and methods based on patient’s interest in and willingness to change the behavior
      • Assist: Using behavior change techniques (self-help and/or counseling), aid patient in achieving agreed-upon goals by acquiring skills, confidence and social/environmental supports for behavior change, supplement with adjunctive medical treatments when appropriate
      • Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support, adjust treatment plan as needed to include referral to more intensive or specialized treatment
    • Up to four brief, face-to-face behavioral counseling interventions covered per year
    • Patient must be competent and alert during counseling
    • Counseling furnished by qualified primary care physician or other primary care practitioner in primary care setting
  • Diagnosis code, for individual Change Requests and coding translations for ICD-10
  • No specific alcohol misuse screening tool required (discretion of practitioner)
  • Both screening and counseling can be covered on same date of service (except RHCs and FQHCs)
  • No more than one G0443 service can be paid for per date of service
  • No payment for additional time spent in screening or counseling
  • No start/stop times required in documentation

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Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

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Reimbursement

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Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

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Common Claim Denial Reasons

  • Covered alcohol misuse screening in last 12 months
  • Received behavioral counseling interventions to reduce alcohol misuse but no claims history in previous 12 months of alcohol misuse screening
  • More than four covered behavioral counseling interventions to reduce alcohol misuse visits in last 12 months

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Related Content

Reviewed 9/27/2024