Is time documentation required for Medicare depression screenings?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

There is no requirement from the Centers for Medicare & Medicaid Services (CMS) to include the amount of time spent in the documentation of depression screening when using the billing code HCPCS G0444 for Medicare beneficiaries .^{1, 2, 3} 

In October 2011, CMS began covering annual depression screening for Medicare beneficiaries in the primary care setting when performed by clinical staff who can advise the physician of screening results and who can help facilitate and coordinate referrals for mental health treatment.¹ The billing code used for this service, HCPCS G0444, appeared in the January 2012 Medicare Physicians Fee Schedule update.

Confusion about whether the amount of time spent needs to be documented to bill for this service may have arisen from a change to the text descriptor for HCPCS G0444 in a January 2023 Medicare Learning Network (MLN) educational document. This document included slightly different language: “HCPCS G0444 – Annual depression screening, 5 to 15 minutes.”³ Prior to 2023, the description was consistent in all CMS materials: “HCPCS G0444, annual depression screening, up to 15 minutes.” 

CMS Manuals provide day-to-day operating instructions to guide the administration of CMS programs. The Depression Screening CMS Manual reads: “...the Centers for Medicare & Medicaid Services (CMS) will cover annual screenings up to 15 minutes for Medicare beneficiaries in primary care settings with staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up.”¹ 

Although documentation that this service was performed is required for billing, a requirement for the amount of time spent performing the service is not included in the related CMS manual, nor in the National Coverage Determination.

Practices can re-evaluate their internal documentation standards, removing or avoiding the necessity for documenting the specific amount of time spent on depression screening to bill for this service. This can save time and reduce unnecessary steps in the workflow.

• Centers for Medicare & Medicaid Services (CMS). Chapter 18 - Preventive and Screening Services. Medicare Claims Processing Manual; 2023. Accessed September 27, 2024. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c18pdf.pdf
• Centers for Medicare & Medicaid Services (CMS). Screening for Depression in Adults; 2011. Accessed September 27, 2024. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=346
• Centers for Medicare & Medicaid Services (CMS). Depression Screening: National Coverage Determination 210.9. MLM Education Tool: Medicare Preventive Services; 2024. Accessed September 27, 2024. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#DEPRESSION
• Download this myth: Depression screening (PDF)

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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.