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Auditing Smoking Cessation Services

By:  John Burns, CPC, CPC-I, CEMC, CPMA
Published:  March 25th, 2016

Most payers do indeed recognize smoking and tobacco cessation services as a covered health insurance benefit. We have found that some providers perform these services without fully understanding the reimbursement opportunities, while others claim such services without adequately documenting to support them. Medicare, for example, will pay for two (2) "quit attempts" or a total of eight (8) face to face visits per year over a 12 month period. Per CMS, each attempt may include a maximum of four intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions in a 12 month period. These services can be covered if rendered by a "qualified doctor or other Medicare-recognized practitioner".

As an auditor, if you discovered that a provider was allowing a registered nurse (RN) for example, to perform smoking cessation services in lieu of the physician or other qualified professional (i.e. PA or NP), that would represent a significant, reportable compliance concern. A participating provider who accepts assignment on a Medicare claim must accept Medicare payment as payment in full; coinsurance and deductible do not apply.

CPT codes 99406 and 99407 (and CMS issues G-codes G0436 and G0437) should be used to report services provided face to face by a physician or other qualified health care professional, using "standardized, evidence-based screening instruments and tools with reliable documentation and appropriate sensitivity." CMS has created two tracking G-codes to report similar services. Essentially, the only difference between the code sets is that the CMS issued G-codes are specified for the "asymptomatic" patient. The 99406 (or G0436 for Medicare) code should be used to report an intermediate visit of between three and ten minutes, and 99407 (or G0437 for Medicare) should be reported for an intensive visit lasting more than ten minutes.

Smoking cessation services (CPT codes 99406-99407) should be reported when performed. The choice of codes depends on the time spent with the patient. Some payers may not require the use of this modifier. An appropriate ICD-10 code (i.e. Z72.0 [tobacco use disorder]) should be appended as a 'principle' on the 1500 claim form. Other ICD- 10 CM codes may include:

  • History of tobacco dependence (Z87.891)

  • Nicotine dependence (F17.2-)

  • Tobacco dependence (F17.2-)

  • Tobacco use during pregnancy (O99.33-)

The current CMS policy suggests that "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, we will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient's hospital stay.

As auditors, we need to pay very careful attention to the provider's documentation of time. In the absence of time being specifically documented, smoking cessation services are not payable. CMS clearly suggests that counseling lasting less than 3 minutes is considered to be part of an evaluation and management (E/M) service and is not paid separately. If an E&M services is provided on the same day as smoking and tobacco-use cessation counseling, providers should choose the appropriate E&M code and use modifier-25 to demonstrate that the E&M service is a separately identifiable service from the smoking and tobacco-use cessation counseling service.

When reviewing notes for which a provider claims smoking cessation, an auditor must consider the following:

  • The amount of time documented specifically engaged in cessation counseling (i.e. 3-10 minutes vs. greater than 10 minutes)

  • The frequency of cessation performed (may require looking at previous 12 months of billing history

  • That a covered ICD-10 code is reported in the principle position on the 1500 claim form (i.e. Z72.0- current tobacco use), and if an E&M service code is reported in addition to smoking cessation services on the same date, they must be individually documented. The level of E&M needs to be supported by the documented levels of history, examination and medical decision making while the smoking cessation service must be consistent with a time statement (minimum of 3 "separately identifiable" minutes) that is distinctly documented in the medical record.

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