Smoking Cessation Counseling: Is it Payable?

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Original story posted on: September 9, 2019

Counseling and treatment are reimbursable.

 Is your medical practice providing smoking cessation counseling and treatment? Did you know you can bill and get reimbursed for your services?

There are rules, linked diagnosis codes, and frequency guidelines to be mindful of, but this is a reimbursable service that physician practices need to capture when performed.

In 2010, the American Cancer Society reported that 7 out of 10 smokers who desired to quit smoking were successful! It is possible to quit smoking with proper help from a physician who takes the time to counsel on the benefits of quitting, along with appropriate prescriptions, if necessary. When smoking is stopped, for even one day, the human body reaps the benefits of overall better health and the decreased risk of cancer.

Effective treatments, according to the American Cancer Society, include the following:

  • Seeing a doctor for advice on quitting
  • Counseling from a physician, group, or telephone
  • Prescription medications and nicotine patches
  • Former smokers report that nicotine gum or candies can help fight the urge, too

In 2014, smoking cessation became a covered benefit under the Patient Protection and Affordable Care Act. This means that Medicare and commercial insurance carriers must provide coverage for smoking cessation counseling and interventions. These services include:

  • Tobacco use screening for all adults and adolescents
  • Tobacco cessation counseling for adults and adolescents who use tobacco, and expanded counseling for pregnant women

So, Who is Covered?
For a Medicare patient to qualify for smoking cessation counseling, they must meet the following requirements:

  • Use of tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
  • A patient must be competent and alert at the time of counseling
  • Counseling must be provided by a qualified physician or other Medicare-recognized healthcare providers (e.g. MD/DO, nurse practitioner, physician assistant, or clinical nurse specialist)
  • (Lower-level clinicians, RNs, MAs, LVNs, LPNs, etc. are not considered qualified healthcare professionals for the purpose of billing smoking cessation services)

Smoking Cessation Counseling Codes 99406 and 99407
Reimbursement is possible if you bill the patient’s insurance company correctly. The 2019 guidelines state that Medicare covers two cessation attempts per 12-month period. Each attempt includes a maximum of up to four intermediate (99406) or intensive (99407) counseling sessions, with a total Medicare benefit of eight sessions per year. This is not per physician; it is per patient. So if you see denials, another physician may have also billed for this service.

The CPT® codes for billing for smoking cessation include:

  • 99406– Smoking and tobacco use cessation counseling visit; intermediate, greater than three minutes, up to 10 minutes
  • 99407– Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

Note: A modifier -25 may be appropriate to append to the primary evaluation and management (E&M) visit code if such a service is performed at the same encounter.

Also note that as of Sept. 30, 2016, HCPCS codes G0436 and G0437 for smoking cessation have been deleted.

Some commonly used ICD-10 diagnosis codes, if appropriate, given your patient’s situation, may include the following:

F17.200 Nicotine dependence, unspecified, uncomplicated (some payers find this code not medically necessary. They are looking for more specificity.)
F17.201 Nicotine dependence, unspecified, in remission
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
Z87.891 Personal history of nicotine dependence
Z71.6  Tobacco Abuse Counseling

Though the billing codes are relatively simple, there are rules to follow, based on the patient’s symptoms.

Check with your local Medicare carrier or private insurance company for their rules and requirements before billing for smoking cessation.

Documentation Requirements
The documentation in the medical record must support the billing of the cessation code. The documentation needs to record what was discussed during counseling, and should show a significant and separately identifiable service.

Items to document may include the following elements:

  • The patient’s tobacco use
  • Whether the patient was advised to quit, and impacts of smoking
  • Assessed willingness to attempt to quit (or resistance to physician’s counseling)
  • Methods and skills for cessation
  • Medication management of smoking session drugs
  • Resources provided
  • Setting a quit date
  • Follow-up arranged
  • Amount of time spent counseling patient

An entry in the patient’s health record simply stating that the doctor spent 11 minutes counseling the patient on tobacco use will not cut it, and will not meet the standard for medical necessity or allow for the proper codes to be billed. Time needs to be documented, as this is a time-based code. However, there should not be a canned time statement, as stated in CPT (e.g. 3-10 minutes spent counseling). The provider should be specific in how much time was spent on face-to-face counseling the patient on smoking cessation (correct starting documentation: eight minutes spent counseling this patient, who is a current smoker….etc.).

Reimbursement for Smoking Cessation
Are you losing money by not coding and billing for smoking cessation? If you are already counseling for smoking cessation in your practice, you are doing the work, so get paid for it.

Medicare’s average reimbursement for 99407, smoking cessation for longer than 10 minutes of counseling, is $27.93.

The 10-minute-or-longer consult may not apply to everyone. The three- to 10-minute counseling code, 99406, reimburses at an average of $14.32. These are national reimbursement amounts, but we advise that you also check your local Medicare Fee Schedule, as payments may vary.

For Medicare, co-insurance and deductibles are also waived, as of 2018. 

Quitting isn’t easy, so make sure your patients know how much you support them, every step of the way!

Programming Note:
Is your practice billing for smoking cessation? Listen to Talk Ten Tuesdays today at 10 a.m. EST when Terry Fletcher reports on the rules of billing smoking cessation services.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS,  ACS-CA, SCP-CA, QMGC, QMCRC

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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