Proper documentation and verifying coverage criteria prior to claim submission can improve your chances for reimbursement.
Many healthcare providers perform tobacco use counseling daily, but they may not be documenting or reporting it appropriately. Reliable guidance is needed to ensure all performed services are claimed and supported by complete documentation.
Where Opportunity Knocks
The Centers for Disease Control and Prevention (CDC) has produced evidence supporting that tobacco use remains the single largest preventable cause of death and disease in the United States. A study in 2010 indicated that seven out of 10 adult smokers wished to quit; however, studies also indicate that only an estimated 4 percent to 7 percent of people are able to quit smoking on any given attempt without medicines or other help. Counseling and other types of support can increase success rates better than medications alone.
The Centers for Medicare & Medicaid Services (CMS) set a standard for coverage (which commercial payers may not follow). Per MLN Matters® article MM7133, CMS will cover tobacco cessation counseling for 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
- Who receive counseling furnished by a qualified physician or other Medicare-recognized practitioner.
Each payer may have its own restrictions for coverage, so inquire about a patient’s benefits prior to claim submission.
Documentation May Determine Payment
As with any time-based evaluation and management (E/M) service, documentation must include sufficient detail to support the claim. Proper documentation for tobacco-use cessation counseling should include the total time spent face to face with the patient, and what was discussed. The patient’s desire or need to quit tobacco use, cessation techniques and resources, estimated quit date, and planned follow up should be noted within the patient’s medical record. Without this information, medical necessity for coverage may be questioned, which could result in denied or delayed payment.
Without documentation of significant and separately identifiable work, the payment for smoking cessation counseling may be included in the payment for the primary E/M service.
Examples of incomplete documentation:
- “I have counseled the patient again to quit smoking. The patient verbalized understanding, but is not ready to quit smoking.”
- “>3 minutes spent counseling patient on tobacco use.”
Proper Billing Means Prompt Reimbursement
Private payers may follow CMS’ direction when it comes to billing requirements for these services; however, it’s important to know your patient’s insurance benefits.
Medicare will cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive counseling sessions.
The total annual benefit covers up to eight smoking and tobacco-use cessation counseling sessions in a 12-month period. The beneficiary may receive another eight counseling sessions during a second or subsequent year after 11 months have passed since the first Medicare covered cessation counseling session was performed.
Example: The beneficiary received the first of eight covered sessions in January 2011. The count starts beginning February 2011. The beneficiary is eligible to receive a second series of eight sessions in January 2012. Medicare’s prescription drug benefit also covers smoking and tobacco-use cessation agents prescribed by a physician.
CMS specifies symptomatic patient criteria as beneficiaries “who use tobacco and have been diagnosed with a recognized tobacco-related disease or who exhibit symptoms consistent with tobacco related disease.”
99406 Smoking and tobacco cessation counseling visit for the symptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
99407 intensive, greater than 10 minutes
G0436 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
G0437 intensive, greater than 10 minutes
These counseling services must be submitted with appropriate diagnosis coding to support medical necessity. The claim and documented encounter should include tobacco use status and confirmed tobacco-related diseases, as appropriate.
Example: A 67-year-old male Medicare patient presents with exacerbated COPD on oxygen. This patient continues to smoke one pack of cigarettes per day after several failed attempts at quitting. Approximately 15 minutes were spent counseling the patient in cessation techniques. He understands continuing to smoke could lead to stroke and death. The benefits of stopping were also presented to him. The patient has verbalized his desire to “give it another try.” He has set his own goal of 30 days to be completely smoke-free. We will follow up in two weeks to check progress.
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
Know Your Patient Coverage
If your clinic is just beginning to provide these services to your patient population, it’s best to verify coverage criteria prior to claim submission. For instance, Preventive Medicine Services guidelines in the CPT® codebook state, “Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.” Many payers group tobacco use cessation counseling under this umbrella and will not reimburse it separately. Knowledge of potential reimbursement errors keeps the denial rate low and provider-patient relationships strong.