Health Information Management

Tip: Read the record closely when coding SBIRT

APCs Insider, December 3, 2010

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Carefully review the way healthcare professionals record concerns and a plan in medical records for structured abuse and brief intervention services (SBIRT)—it matters.

Physicians must clearly document everything. Coders can’t make assumptions. If the physician just says “alcohol abuse” or “history of alcohol abuse”’ don’t assume that the patient drinks continually. This is true despite CMS guidance for SBIRT coding that states that if providers don’t document the reason for tests and services, rationale for the order should be “easily inferred.”

Look in the chart for specific indicators that led the physician or provider to believe the patient needed these assessment and intervention services. For example, the record might state that the patient’s annual blood workup came back with borderline results or that the patient reported consuming five drinks daily (e.g., lunch, happy hour, dinner, etc.).

Finally, note how long a provider spends giving these services. These codes are determined by time units, so be sure the provider documented the time.

This tip was adapted from “Look for medical necessity, signs and symptoms, and time units when coding abuse and brief intervention services” in the November issue of Briefings on APCs.



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