Business Briefs: Smoking Cessation Counseling: Coding, Payment, & Coverage

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader. 

Like most of us could say, I can remember my parents educating me at a very young age about the dangers of smoking and that it’s “bad for your health.” Of course, these were messages my parents had to constantly deliver as I was growing up because many movie stars and recording artists smoked, as did many members of my family and friends. If you’re wondering if I always followed my parents’ advice, the answer is a definitive “yes,” because in their home you followed the house rules — or else! Looking back to when I began working in hospital settings, I remember the physicians’ lounges and the cafeterias were always smoke-filled. In 1964, Surgeon General Dr. Luther Terry of the U.S. Public Health Service (PHS) proved my parents were smarter than I gave them credit for as a youngster when his advisory committee released the Report on Smoking and Health that officially recognized cigarette smoking as a cause of cancer and other serious diseases. Fairly quickly after the report was released, physicians’ lounges, cafeterias, and other common areas were no longer smoke-filled. Smoking was no longer permitted in many workplaces as well as (finally) on commercial airplanes – and to think that was once permitted! 

Over the last few years Medicare Administrative Contractors (MACs) began including smoking cessation guidelines into wound care-related local coverage determinations (LCDs). These LCDs have caused some wound care physicians to ask me to research whether Medicare and other payers reimburse for smoking and tobacco cessation counseling. Following are the findings of this research. 

Does A Code Exist For This Work? 

In 2005, the Centers for Medicare & Medicaid Services (CMS) created two temporary “G” codes — G0375 and G0376 — for billing smoking and tobacco cessation counseling services provided to symptomatic individuals. MACs were instructed to accept the counseling codes with revenue code 0942 (Education Training). 

In 2008, those temporary codes were replaced with permanent Current Procedural Terminology (CPT^®) codes. These codes are in the Evaluation and Management (E/M) section of the 2016 CPT book under the following headings, subheadings, and subcategories: 

• Preventive Medicine; 
• Counseling Risk Factor Reduction and Behavior Change Intervention; 
• New or Established Patient; and 
• Preventive Medicine, Individual Counseling. 

99406 - Smoking and tobacco-use cessation counseling visit; intermediate, > 3 minutes, up to 10 minutes; 

99407 - Smoking and tobacco-use cessation counseling visit; intensive, > 10 minutes. 

NOTE: 99406 and 99407 should not be used for smoking and tobacco cessation counseling < 3 minutes. That work is included in the counseling component of E/M services. 

Standardized, evidence-based screening instruments and tools with reliable documentation and appropriate sensitivity are required to separately report for these services. The codes should be used to report a face-to-face encounter by physicians or other qualified healthcare professionals (QHPs) to discuss smoking and tobacco cessation counseling. Codes 99406 and 99407 are distinct from E/M services. If an abnormality is encountered or a pre-existing problem is addressed in the process of performing the smoking and tobacco cessation counseling, and if the problem/ abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate E/M code (99201-99215; office or other outpatient services) should also be reported. 

NOTE: The time spent in smoking/tobacco cessation should not be used as a basis for the E/M code selection. Modifier -25 should be added to the E/M code to indicate a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service. In that case, the appropriate smoking and tobacco cessation counseling is additionally reported. The smoking and tobacco counseling should be documented: along with: 

• assessment of patient’s readiness for change; 
• barriers to change; 
• advice provided to change behavior (specific actions suggested and motivational counseling); and 
• arrangement for services (eg, pharmacologic interventions, nicotine replacement, community support groups, etc.) and follow up to provide encouragement and additional counseling. 

Effective Aug. 25, 2010, CMS created two new “G” codes for billing tobacco cessation counseling services to prevent tobacco use by asymptomatic patients: 

1. G0436 - Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, > 3 minutes, up to 10 minutes; and 

2. G0437 - Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, > 10 minutes. 

These are in addition to the two CPT codes 99406 and 99407 that are used for tobacco cessation counseling for symptomatic individuals. Similar to 99406 and 99407, MACs shall accept revenue code 0942 on physician and other QHP claims as well as wound care hospital-based outpatient department claims. MACs shall allow payment for a medically necessary E/M service (when it is clinically appropriate) on the same day as the smoking and tobacco cessation counseling service. Physicians and other QHPs shall use an appropriate code to report an E/M service with modifier -25 to indicate the E/M service is a separately identifiable service from G0436 or G0437.

What Are the National Average Medicare Payment Rates? 

Physicians and Other QHPs: 

99406: Office - $14.32 (Medicare $11.46; patient copayment $2.86) 

Facility - $12.53 (Medicare $10.02; patient copayment $2.51) 

NOTE: The global concept does not apply to this code. 

99407: Office - $27.93 (Medicare $22.34; patient copayment $5.59) 

Facility - $26.14 (Medicare $20.91; patient copayment $5.23) 

NOTE: The global concept does not apply to this code. 

Section 4104 of the Affordable Care Act (ACA) provides for a waiver of the Medicare coinsurance and Part B deductible requirements for G0436 and G0437. 

G0436: Office - $14.68 

Facility - $12.53 

NOTE: The global concept does not apply to this code. 

G0437: Office - $27.93 

Facility - $26.14 

NOTE: The global concept does not apply to this code. 

Wound Care HOPDs: 

99406: Ambulatory Payment Classification (APC) Group 5821 - $27.12 (Medicare $21.69; patient copayment $5.43) 

Status Indicator “S” = separate APC payment 

99407: APC Group 5821 - $27.12 (Medicare $21.69; patient copayment $5.43) 

Status Indicator “S” = separate APC payment. 

Section 4104 of the ACA provides for a waiver of the Medicare coinsurance and Part B deductible requirements for G0436 and G0437 effective on or after Jan. 1, 2011. 

G0436: APC Group 5821 - $27.12 

Status Indicator “S” = separate APC payment 

G0437 APC Group 5822 - $69.65 

Status Indicator “S” = separate APC payment. 

Does Medicare Cover It?

National Coverage Determination (NCD) for Symptomatic Patients 

On March 22, 2005, CMS determined the U.S. Surgeon General’s evidence is adequate to conclude smoking and tobacco cessation counseling, based on the current PHS guideline, is reasonable and necessary for certain symptomatic individuals who use tobacco and live with a disease or an adverse health effect found by the Surgeon General to be linked to tobacco use or those who are taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on U.S. Food and Drug Administration-approved information. These individuals will be covered under Medicare Part B when certain conditions of coverage are met, subject to certain frequency and other limitations. 

On July 5, 2005, CMS implemented the first NCD entitled NCD for Smoking and Tobacco-Use Cessation Counseling (210.4). The NCD is pertinent to clinical social worker services, incident to a physician’s professional services, outpatient hospital services incident to a physician’s service, physicians’ services, qualified psychologist services, and rural health clinic services. Intermediate and intensive smoking cessation counseling services will be covered for outpatient and hospitalized beneficiaries who are smokers and who qualify, as long as those services are furnished by qualified physicians and other QHPs. To be covered, patients must be competent and alert at the time counseling services are provided. Minimal (< 3 minutes) smoking and tobacco counseling should be covered as E/M visits. Beyond that, Medicare will cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive sessions, with the total annual benefit covering up to eight sessions in a 12-month period. See Table 1 for definitions of “attempts” and “sessions.” 

MACs shall allow payment for a medically necessary E/M service, when it is clinically appropriate, on the same day as the smoking and tobacco cessation counseling service. Physicians and other QHPs shall use codes 99201-99215 to report an E/M service and modifier -25 to indicate the E/M service is a separately identifiable service from a smoking and tobacco cessation counseling service. Diagnosis codes should reflect: 

• the condition the patient lives with 
• that is adversely affected by tobacco use or 
• the condition the patient is being treated for with a therapeutic agent whose metabolism is affected by tobacco use. 

CMS provides the following covered primary ICD-10-CM codes for nicotine use (see Table 2). 

CAUTION: These primary diagnosis codes require an additional diagnosis for a disease or an adverse health effect linked to tobacco use, or for a patient who is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use. 

For a complete listing of the additional covered ICD-10 codes that must be reported, visit www.cms.gov/ regulations-and-guidance/guidance/ transmittals/downloads/r1199otn4.zip. NOTE: Medicare’s prescription drug benefit will also cover smoking and tobacco cessation agents prescribed by a physician. 

NCD for Asymptomatic Patients 

Effective Aug. 25, 2010, CMS implemented another NCD entitled NCD for Counseling to Prevent Tobacco Use (210.4.1) that extends national coverage for cessation counseling to those individuals who use tobacco but do not have signs or symptoms of tobacco-related disease. CMS covers tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries: 

• who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease; 
• who are competent and alert at the time counseling is provided; and 
• whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner. 

Similar to existing tobacco cessation counseling for symptomatic individuals, CMS will allow two individual tobacco cessation counseling attempts per 12-month period. Each attempt may include a maximum of four intermediate or intensive sessions, with a total benefit covering up to eight sessions per 12-month period per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (> 3 minutes, but < 10 minutes) or intensive (> 10 minutes) cessation counseling sessions for each attempt. 

The beneficiary may receive another eight sessions during a second or subsequent year after 11 full months have passed since the first Medicare-covered counseling session was performed. To start the count for the second or subsequent 12-month period, begin with the month after the month in which the first Medicare-covered counseling session was performed and count until 11 full months have elapsed. 

NOTE: By entering the beneficiary’s health insurance claim number, providers have the capability to view the number of sessions a beneficiary has received for this service via inquiry through the common working file. 

NOTE: Inpatient hospital stays with the principal diagnosis of tobacco use disorder are not reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, CMS will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient’s hospital stay. 

See Table 3 above for a list of covered ICD-10 diagnosis codes CMS provides with this NCD. 

Documentation

Similar to all separately payable services, documentation is paramount. Physicians should first document that the patient expressed a willingness or desire to try to quit smoking. Physicians should also document prescriptions written, prescriptions refilled, or prescriptions discontinued related to smoking cessation. 

If the physician provided the patient with any educational material (eg, risks of smoking, how to quit smoking, risks of smoking on the patient’s general health, how smoking might impact wound healing, how smoking will impact the ability to gain payer coverage for the application of cellular and/or tissue-based products for skin wounds, etc.), this should also be noted. 

In addition, the physician or other QHP must document the time spent counseling the patient in order to bill for any smoking cessation service. Physicians and other QHPs should document (and keep on file) Medicare beneficiary medical records adequate to demonstrate, upon medical review, that the NCD coverage requirements have been met. By submitting a claim for smoking and tobacco cessation counseling services, physicians and QHPs are asserting such coverage requirements have been met. 

Post-Payment Review For Smoking & Tobacco Cessation Counseling

As with any claim, Medicare may decide to conduct post-payment reviews to determine the services provided are consistent with coverage instructions. Providers must keep patient records information on file for each Medicare patient for whom a smoking and tobacco cessation counseling claim is made. These medical records can be used in any post-payment review and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed. 

Do Private Payers Cover It? 

Unlike Medicare, many private payers do not cover smoking cessation counseling; they consider the counseling to be part of the E/M service. Therefore, it is essential that physicians and other QHPs conduct insurance benefit verification with private payers before providing the counseling service. 

 Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, biotherapeutics at Smith & Nephew.