EDITOR’S NOTE: This article has been updated to include commercial contract coverage information and CPT® direction to challenge payer contract provisions when necessary.
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. We try to stick to the Medicare/CMS (Centers for Medicare & Medicaid Services) policies and provisions, as they are the gold standard, and many private payers also profess to “follow Medicare guidelines.” You will run into different commercial plan contracts that have different billing rules, and if you sign the contracts, you will have to follow the rules.
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 each patient on the benefits of quitting smoking, 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 decreased risk of cancer.
Effective treatments, according to the American Cancer Society, include:
- Seeing the 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.
Can You Bill for Smoking Cessation Services?
In 2014, smoking cessation became a covered benefit under the Patient Protection and Affordable Care Act (PPACA). 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:
- The patient must use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease.
- The 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 CMS 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, or per attempt, but per patient. If you see denials, another physician may have also billed for this service.
The CPT codes for billing for smoking cessation include:
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.
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 when billing Medicare, based on the patient’s symptoms.
The Medicare Learning Network (see link below) from CMS provides information that may also be helpful.
Check with your local Medicare carrier or private insurance company for their rules and requirements before billing for smoking cessation.
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
- Advisement to quit and impact 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. 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 of the patient on smoking cessation (correct: eight minutes spent counseling this patient, who is a current smoker).
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 3-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.
- 99406 = $27.93
- 99407 = $14.32
Medicare co-insurance and deductibles are waived, as of 2018.
I recently reviewed a commercial plan policy stating that there “has to be a plan documented and the patient’s agreement to quit smoking” for the service to be payable under their contract. I would take issue with this payer, only in the sense that the behavior change intervention CPT codes specifically state in their narrative directions that “behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling, and arranging for services (e.g. prescriptions) and follow-up.”
So having a payer that will not allow a physician to code for these services just because the patient isn’t ready to make the change defeats the spirit and the language of the risk factor reduction counseling, through which the provider attempts to change addictive behavior. It would be like documenting a level 5 E&M code, but because the patient isn’t ready to have a high-risk surgery, telling the physician you have to downcode your E&M, based on the patient’s readiness for surgery. The recommendation, discussion, and overall risk still exist. This would not negate the level 5 visit.
You may have to adhere to what your payer says, if you signed their contract, but I would try and argue the point if your documentation reflects the physician doing their part of encouraging smoking cessation and making recommendations for the patient on a plan for quitting smoking – even if the patient isn’t ready to comply.
It is important that as healthcare professionals, we support our physicians in their efforts when smoking cessation services are performed. This means we need to look at policy provisions, review language in payer contracts, and appeal, when necessary and if possible.