An Update on Tobacco Cessation Reimbursement
Slowly but surely, it's getting easier to help your patients kick the habit.
Fam Pract Manag. 2006 May;13(5):75-78.
Even when your patients aren't ready to quit smoking, they want you to encourage them to quit. According to a recent survey of smokers, patients whose primary care physicians counseled them about smoking were more satisfied with their care than patients whose physicians didn't offer counseling.1 In fact, as the number of counseling interventions increased, satisfaction with care increased.
If you aren't broaching the subject with patients, you're not alone. The AAFP Tobacco Cessation Advisory Committee analyzed surveys performed by Mathematica Policy Research Inc. and the AAFP. The research indicated that only 70 percent of family physicians ask their patients about tobacco use and only about 40 percent take action to help patients quit. Lack of reimbursement (after lack of time and lack of knowledge) was one of the most common reasons physicians gave for not offering intervention. As payers find that covering tobacco cessation treatment is cost-effective, reimbursement for these services is becoming less of a barrier.
Medicare and Medicaid coverage
In March 2005, Medicare Part B coverage was expanded to include two new levels of smoking and tobacco cessation counseling – intermediate and intensive. The new coverage is for patients who use tobacco and have 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 [are] taking a therapeutic agent whose metabolism or dosing is affected by tobacco use.”2 Medicare will pay for two quit attempts per year, both of which can include up to four intermediate or intensive sessions. Up to eight sessions in a 12-month period are covered.
Coverage for up to three minutes of counseling is considered by Medicare to be included in reimbursement for the standard evaluation and management (E/M) office visit. When billing for more than three minutes of smoking and tobacco cessation counseling, use the following HCPCS codes:
G0375: Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes. Short descriptor: Smoke/Tobacco counseling 3–10;
G0376: Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes. Short descriptor: Smoke/Tobacco counseling greater than 10.
Medicare's national average reimbursement rate for G0375 is $12.89; the average rate for G0376 is $25.39. Rates vary by geographic location.
Claims for smoking and tobacco cessation counseling should be submitted with the appropriate diagnosis code. Diagnosis codes should reflect the patient's condition that is adversely affected by the use of tobacco or the therapeutic agent that is affected by the use of tobacco.
If you need to bill for E/M services on the same day, use the appropriate code in the 99201–99215 range with modifier −25 attached to show that the E/M service is significant and separately identifiable from the tobacco cessation counseling.
Also note that as of January 2006, Medicare Part D covers physician-prescribed smoking cessation treatments. (Over-the-counter treatments such as nicotine gum and nicotine patches are not covered.)
You should also be sure to inform your Medicaid patients who use tobacco products that they can obtain financial and medical assistance with tobacco cessation. Medicaid rarely publicizes this coverage, which has increased dramatically over the past 10 years. Thirty-six states, as well as the District of Columbia, now cover one or more treatments for tobacco dependence. To learn more about Medicaid coverage in your state, contact your state Medicaid agency or visit the Kaiser Family Foundation's Web site at http://statehealthfacts.org (click on “Medicaid & SCHIP” and then “Cessation Treatment Under Medicaid”).
Private insurance coverage
You and your privately insured patients can take a more proactive approach to tobacco cessation treatment and counseling by becoming familiar with the coverage offered by patients' health plans. You might be pleasantly surprised by what you find. For one thing, patients are much more likely than in the past to get coverage for pharmacotherapy for tobacco cessation. According to a survey by America's Health Insurance Plans, the percentage of insurers providing full coverage for pharmacotherapy for tobacco cessation more than tripled from 1997 to 2002.3 The vast majority of insurers surveyed provided full coverage to their members for at least one type of pharmacotherapy for tobacco cessation, as well as at least one type of behavioral intervention, including face-to-face counseling.
Although 34 percent of survey respondents reported having increased reimbursement to providers for smoking cessation counseling or assistance, many payers still provide little or no payment. In such cases, treatment must be incorporated into a comprehensive preventive medicine visit or an E/M visit.
When plans do cover counseling, physicians can bill for it using the ICD-9 code for tobacco dependence, 305.1, along with the appropriate CPT code for preventive medicine counseling and risk factor reduction intervention services (99401–99404). It is important to note that codes 99401–99404 should not be used to report counseling and risk factor reduction involving patients with symptoms or established illness. If the patient has chronic obstructive pulmonary disease or chronic bronchitis, for instance, your counseling would be billed with an office or other outpatient, hospital or consultation code as appropriate. Although there are psychiatric therapeutic codes appropriate for treating tobacco dependence, some health plans have restrictions on mental health benefits that make it difficult for family physicians to get paid for these services.
If a patient's health plan doesn't cover these services, patients may be willing to pay out of pocket. Tobacco cessation treatments are eligible expenses under many flexible spending account plans, which enable patients to use pretax dollars to pay for health care expenses not covered by insurance. These plans are now offered by thousands of employers.
A growing number of resources should make it easier for patients to quit using tobacco and for physicians to help them do it.
AAFP. The AAFP's new tobacco cessation campaign, “Ask and Act,” encourages family physicians to ask about the tobacco use habits of all their patients and then act on that information. Through the campaign, which is funded by the Smoking Cessation Leadership Center, AAFP members can access a variety of resources to help patients kick the habit. The materials – some new and some obtained from other sources – are available at http://www.aafp.org/tobacco.xml.
In addition, physicians can make an impact in as little as 30 seconds by referring patients to toll-free quit lines. While quantities last, AAFP members can get free plastic quit line cards by calling the order department at 800–944–0000 and requesting item #966. The cards carry the number for the National Network of Tobacco Cessation Quit lines: 800-QUIT-NOW. By calling this number, patients can receive immediate advice on quitting, referrals to other sources and an offer to have materials mailed to them.
American Cancer Society. Patients can visit http://www.cancer.org and view the “Guide to Quitting Smoking” for tips on quitting, as well as information about nicotine addiction and withdrawal.
Department of Health & Human Services. At http://www.surgeongeneral.gov/tobacco/, you can find information on tobacco cessation for clinicians and patients, as well as reports, press releases and speeches from the U.S. Surgeon General.
Smokefree.gov. This site, created by the Tobacco Control Research Branch of the National Cancer Institute (NCI), offers help to those ready to quit. Smokefree.gov provides an online step-by-step cessation guide, local and state telephone quit lines, NCI's national telephone quit line, NCI's instant messaging service and several publications, which may be downloaded, printed or ordered.
Addressing tobacco use with your patients is an important step in improving their health. Your help and encouragement, combined with resources like these, will help patients believe that quitting is within their reach.
About the Authors
Mary Theobald is a health care communications consultant in Raymore, Mo., managing the AAFP's Ask and Act tobacco-cessation campaign. Dr. Jaén is co-director of the Center for Research in Family Medicine and Primary Care. He is also professor and chairman of Family and Community Medicine at the University of Texas Health Science Center at San Antonio. Author disclosure: nothing to disclose.
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1. Conroy MB, Majchrzak NE, Regan S, Silverman CB, Schneider LI, Rigotti NA. The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers' satisfaction with their health care. Nicotine Tob Res. 2005;7(suppl 1):S29–S34.
2. Centers for Medicare & Medicaid Services. Decision memo for smoking & tobacco use cessation counseling. Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=130. Accessed April 18, 2006.
3. McPhillips-Tangum C, Bocchino C, Carreon R, Erceg C, Rehm B. Addressing tobacco in managed care: results of the 2002 survey. Prev Chronic Dis. 2004;1(4):A04.
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