Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services, previously known as the Health Care Financing Administration, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state government…
What is the CPT code for smoking cessation?
99406-Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes and up to 10 minutes 99407-Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes These codes reflect behavior-change intervention services and should be precluded by a validation that the patient’s readiness was assessed.
Does Medicare reimburse for tobacco use cessation?
Therefore, Medicare will not reimburse for tobacco use cessation services if tobacco use cessation is the primary reason for the patient’s hospital stay. Thirty commenters expressed the opinion that quitlines and/or web based services should be considered covered practitioners.
How many smoking cessation counseling sessions does Medicare cover?
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.
Is smoking cessation counseling included in the payment for primary E/M?
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. “I have counseled the patient again to quit smoking.
What is the CPT code for smoking cessation for Medicare?
99406Smoking Cessation Counseling Codes 99406 and 99407 Medicare covers 2 cessation attempts per 12-month period. Each attempt includes a maximum of up to 4 intermediate (99406) or intensive (99407) counseling sessions, with a total Medicare benefit of 8 sessions per year.
Is there a separate Medicare G code for smoking cessations?
CMS has advised its Medicare contractors to replace code G0436 with CPT code 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and replace code G0437 with CPT code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 ...
How do you code a smoking cessation?
Codes G0436 and G04037 were deleted that represented asymptomatic cessation counseling. According to the Medicare Preventive Services guide, Medicare suggests the use of codes 99406 and 99407.
What ICD-10 code to use for smoking cessation?
F17. 201 Nicotine dependence, unspecified, in remission. F17. 210 Nicotine dependence, cigarettes, uncomplicated.
What is G0463 used for?
HCPCS Code G0463 is used for all FACILITY evaluation and management visits, regardless of the intensity of service provided.
What is CPT code G0438?
G0438 is the HCPCS code you should use when coding a patient's first annual wellness visit. Its long descriptor is "Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit," while its short descriptor is "Annual wellness first."
What modifier do you use with 99406?
25”To allow payment in this circumstance, providers should append a “25” modifier for 99406 or 99407 codes. Magnolia Health (MH) indicates that 99406 and 99407 are reimbursed with no modifier or diagnosis limitations.
What is CPT code 1036F?
CPT® Code 1036F - Patient History - Codify by AAPC.
Is G0436 a valid CPT code?
1, CMS will no longer consider valid for Medicare purposes CPT codes G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) and G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than ...
Can 90471 and 99406 be billed together?
If you check the CCI edits, you'll see that 99406 is a Column 2 code when billed with 90471. You need either a -59 modifer OR one of the X{EPSU} modifiers on 99406 if it is supported by the documentation as a separate service.
What is diagnosis code r079?
ICD-9 Code Transition: 786.5 Code R07. 9 is the diagnosis code used for Chest Pain, Unspecified. Chest pain may be a symptom of a number of serious disorders and is, in general, considered a medical emergency.
How many cessation attempts does CMS cover?
CMS will cover two cessation attempts per year. An attempt may include up to four intermediate or intensive sessions, so up to eight sessions could be covered in a 12-month period. It must be noted that other payers may cover cessation attempts at different frequencies.
How long does a 99406 counseling visit take?
99406-Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes and up to 10 minutes. 99407-Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes.
Is there a smoking cessation policy for LG XL?
LG. XL. There are no required guidelines on what type of smoking cessation should be administered, but the service should be documented and reported.
Is smoking cessation care billed?
Answer: Smoking cessation care is often administered and not billed. In other instances, it may be billed, but not fully supported in the documentation. While this is a medically necessary and payable service, there are some documentation requirements to support billing, which are more substantial than simply including the phrase “smoking cessation ...
Decision Summary
The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that smoking and tobacco use cessation counseling, based on the current U.S. Public Health Service (PHS) Guideline, is reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S.
Decision Memo
The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that smoking and tobacco use cessation counseling, based on the current U.S. Public Health Service (PHS) Guideline, is reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S.
How many counseling sessions are covered by Medicare?
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.
What is CPT code 99381?
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.#N#Resources#N#www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf#N#www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7133.pdf#N#www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/#N#www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-success-rates
How to improve your chances of reimbursement?
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 ...
Does Medicare cover cessation counseling?
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.#N#Medicare will cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive counseling sessions.#N#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.#N#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.#N#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.”#N#CPT® descriptions:#N#99406 Smoking and tobacco cessation counseling visit for the symptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes#N#99407 intensive, greater than 10 minutes#N#G0436 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes#N#G0437 intensive, greater than 10 minutes#N#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.#N#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.#N#CPT® coding:#N#99407#N#ICD-10-CM coding:#N#F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders#N#J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
How long does it take to get tobacco cessation counseling?
Medicare Part B (provider component) covers two levels of tobacco cessation counseling for symptomatic and asymptomatic patients: intermediate (great than 3 minutes but no more than 10 minutes) and intensive (greater than 10 minutes).
What is HCPCS coding?
Similar to the CPT code set, HCPCS is a standardized coding set used by the Centers for Medicare and Medicaid Services, as well as other payers. Like CPT, it includes three levels or categories of codes:
What is the F17 code?
The F17 codes are used if the patient is dependent on tobacco. The Z codes are used if there is NOT dependence on tobacco. The Z codes cannot be combined with an F17 code.
What is CPT medical?
It provides a uniform mechanism for describing services and procedures among providers, payers, and patients, as well as coders and analytical entities. For this document, CPT establishes what services or procedures have been provided and the basis for payment by payers.
What is the ICD-10 code used for?
ICD-10 codes are used by physicians and other health care providers to classify and code all diagnoses, symptoms, and procedures in U.S. health care settings on claims for services provided. These codes are used by payers to determine coverage, not the amount that will be paid. Separately, payers have schedules which match the codes to the specific provider’s negotiated rate.
What is Medicaid managed care?
Medicaid managed care organizations (MCOs) are required to provide at least a comparable level of benefits to the fee-for-service option (77 percent of state Medicaid recipients are currently served by Medicaid MCOs).
Is tobacco use covered by Medicare?
Tobacco use status is now embedded in most of the major electronic health records and evidence-based tobacco cessation counseling and pharmacotherapy covered by Medicare, Medicaid and most private health plans. Despite improved documentation and coverage, few providers bill for cessation services.
I. Decision
- The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that smoking and tobacco use cessation counseling, based on the current U.S. Public Health Service (PHS) Guideline, is reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S. Surgeon...
II. Background
- Tobacco use continues to be the leading cause of preventable death in the United States. In 1964, the Surgeon General of the U.S. Public Health Service issued the report of his Advisory Committee on Smoking and Health, officially recognizing that cigarette smoking is a cause of cancer and other serious diseases. Though smoking rates have significantly declined, 9.3 percent (95% CI = …
III. History of Medicare Coverage
- The Centers for Medicare & Medicaid Services (CMS) has not previously issued a National Coverage Determination for smoking and tobacco use cessation counseling. Local Medicare contractors currently have discretion to cover these services when they determine them to be medically necessary for the individual patient. The benefit categories for smoking cessation cou…
IV. Timeline of Recent Activities
- On June 23, 2004, CMS accepted a request from the President of Partnership for Prevention to expand coverage for tobacco cessation counseling. Their letter requested that CMS cover tobacco cessation counseling for Medicare beneficiaries with smoking related disease or symptoms of smoking related disease as detailed in the PHS 2000 Guideline.
v. General Methodological Principles
- When making national coverage decisions, CMS evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a finding that an item or service is reasonable and necessary. The overall objective for the critical appraisal of the evidence is to determine to what degree we are confident that: 1) specific clinical questions relevant to the cov…
VI. Evidence
- A. Introduction Smoking cessation (abstinence) information is a substitute endpoint (surrogate) for the important clinical measures of improved health outcomes in the evaluation of the effectiveness of cessation counseling. The effectiveness of tobacco use counseling can be judged based on the ability to bring about abstinence, as abstinence has been shown to improv…
VII. CMS Analysis
- National coverage determinations (NCDs) are determinations by the Secretary with respect to whether or not a particular item or service is covered nationally under title XVIII of the Social Security Act § 1869(f)(1)(B). In order to be covered by Medicare, an item or service must fall within one or more benefit categories contained within Part A or Part B, and must not be otherwi…
VIII. Decision
- The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that smoking and tobacco use cessation counseling, based on the current PHS Guideline, is reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use, or who is tak…