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Cracking the (Billing) Code: What to Know about Interprofessional Consultations for SUD
This blog is part of ASAM’s ‘Recovery Readout’ series, which breaks down the latest data and trends impacting addiction medicine and practice management.
Data in Focus
Almost 7 million Medicare beneficiaries had a substance use disorder (SUD) in 2023, but nearly 80% did not receive treatment.
Extensive workforce gaps mean that patients needing SUD treatment may wait extended periods to see a clinician willing to treat SUD, especially if their condition is severe and requires treatment by a specialist.
Though the percentage of Medicaid patients with a severe SUD was twice that of Medicare patients, just 37% of severe cases in Medicare received any treatment, compared to 48% of severe cases in Medicaid. This indicates a potentially significant gap in access to specialty addiction treatment for Medicare beneficiaries with severe SUD.
However, there are billing codes that primary care clinicians can use to report consulting with a specialist on a patient’s care, including in situations where the treating clinician may not have the requisite training for severe cases.
While billing of these services (by treating and consulting clinicians alike) by general practitioners such as family medicine, generalists, and internists has remained robust, addiction specialist physicians (ASPs) in Medicare do not appear to be using the codes for providing expert consultations. ASPs billed only 7 interprofessional consultation services in 2024, up from 2 services in 2020.1
Notably, use of these services by nurse practitioners (NPs) and physician associates (PAs) has exploded by more than 300% since 2020.2
One barrier to greater code use for consulting specialists in Medicare is that the national average Medicaid rate for this service can be upwards of $53 per service while the same service in Medicare is paid at $37.
Zoom Out
Since 2019, Medicare has allowed those who can report evaluation and management services (physicians, NPs/PAs) to report initiating the outreach for interprofessional consultation services. Medicaid followed that with a policy change permitting coverage of these services in 2023. Medicaid covers a big chunk of those who have SUD. It’s also possible that ASPs are just seeing more Medicaid than Medicare patients.
These CPT codes are used to report consultations provided via telephone, internet, or electronic health record (EHR) to a treating physician by a consulting clinician (usually a specialist) who does not see the patient face to face.
The following codes can be reported by the consulting clinician:
| CPT code | Code descriptor |
| 99446 | Interprofessional telephone/internet/EHR assessment and management service provided by a consultative physician or other QHP, which must include a verbal and a written report to the patient’s treating/requesting physician or other QHP; five to 10 minutes of medical consultative discussion and review |
| 99447 | …11 to 20 minutes of medical consultative discussion and review |
| 99448 | …21 to 30 minutes of medical consultative discussion and review |
| 99449 | …31 minutes or more of medical consultative discussion and review |
| 99451 | …which must include a written report (no verbal report, as with 99446) to the patient’s treating/requesting physician or other QHP; 5 minutes or more of medical consultative time |
The treating clinician may report the following code for initiating outreach to the consulting clinician:
99452: Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes
The Impact
The data indicate that Medicare patients who have a severe SUD may find it more challenging to get specialty treatment than similarly situated patients with Medicaid, potentially due to low Medicare reimbursement for expert consultation services by ASPs, or even the simple fact that ASPs may just be treating a disproportionately higher share of Medicaid than Medicare patients.
At the same time, Medicare coverage of SUD treatment is limited, meaning that some patients with more severe cases may find themselves in levels of care not commensurate with their severity, often without access to an ASP.
Together, these factors may limit the availability of ASPs to primary care clinicians treating patients with severe cases of SUD.
While the data sample on ASPs billing of these services in Medicare is small, what’s available may suggest that there is a bigger role for ASPs to play in helping primary care clinicians navigate SUD treatment, especially for patients with severe SUD.
Takeaways
Coding and payment is available for treating clinicians and ASPs alike to report interprofessional consultations provided via telephone, internet, or EHRs.
However, CMS should examine whether payment differentials between Medicare and Medicaid for interprofessional consults have any impact on uptake.
Due to Medicare coverage limitations, patients with a severe SUD may strongly benefit from collaboration between their treating clinician and an ASP, especially because patients pay no cost-sharing for these interprofessional consultation services.
Primary care clinicians and ASPs should review CPT coding and guidelines for interprofessional consultations to determine whether these codes would be a good fit for their practice.
Federal and state laws, regulations, and policies that may discourage this type of collaboration should be examined.
Stories Behind the Stat
Go Deeper
Medicare recently unveiled new interprofessional consultation codes for clinicians treating behavioral health issues and who cannot bill E/M services (such as mental health therapists, psychologists, etc.). For more information, click here.
For more information on the codes and restrictions, check out this resource.
1 ASAM staff analysis of Medicare Fee for Service utilization data from 2020 and 2024. Does not include Medicare Advantage data.
2 Ibid
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