Comments to CMS re: the Draft Decision Memo for Smoking & Tobacco Use Cessation Counseling

Steve Phurrough, MD, MPA
Director, Coverage and Analysis Group
Centers for Medicare and Medicaid Services (CMS)
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Phurrough:

I am writing on behalf of the American Academy of Family Physicians, which represents more than 94,000 physician and medical students nationwide. Specifically, I am writing to offer our comments on the Draft Decision Memo for Smoking & Tobacco Use Cessation Counseling (CAG-00241N) that CMS released on December 23, 2004.

In the draft decision memo, CMS proposes 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 General to be linked to tobacco use, or who is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on FDA-approved information. The counseling may only be provided by individuals trained in tobacco use cessation counseling.

CMS notes that minimal counseling is already covered at each evaluation and management visit. Beyond that, Medicare proposes to cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive sessions, with the total annual benefit covering up to eight sessions in a 12 month period. The physician or other health care professional and the patient have flexibility to choose between intermediate or intensive cessation strategies for each attempt.

The American Academy of Family Physicians enthusiastically supports the proposed coverage policy. It is a step in the right direction and consistent with AAFP policy that supports health plan coverage and appropriate reimbursement for evidence-based physician services for treatment of tobacco use, including nicotine replacement therapy and behavioral modification. Nicotine replacement therapy (both prescribed and over-the-counter) is an effective component of tobacco cessation treatment and generally increases rates of smoking cessation especially when combined with behavioral modification. These FDA-approved therapies are described in the USPHS Clinical Practice Guideline entitled, Treating Tobacco Use and Dependence, Revised June 2000, U.S. Public Health Service. Further, the American Academy of Family Physicians urges members to work cooperatively with other health professionals to provide cessation counseling and other treatments, consistent with the proposed policy.

As CMS moves to implement this policy, we believe it will need to address several questions:

What is a “session?” The coverage policy indicates that Medicare will cover a maximum of four intermediate or intensive sessions per attempt, with the total annual benefit covering up to eight sessions in a 12 month period. CMS’s use of the word “session” implies a face-to-face encounter with the health care professional providing the smoking cessation counseling. However, office-based cessation efforts often involve physician or nurse phone calls interspersed with office visits. If these phone calls count as “sessions,” then the limit of four “sessions” per attempt may not be enough. If these phone calls do not count as “sessions,” then we are curious how CMS will treat such phone calls. Also, what constitutes an “intermediate” versus an “intensive” session?

What kind of training counts? CMS states that the counseling may only be provided by individuals trained in tobacco use cessation counseling. However, CMS does not specify the amount and level of training required. Family physicians receive such training as part of their residency training, and we believe that family physicians are qualified to provide smoking cessation counseling based on that training.

How will physicians code for these services, and how much will Medicare pay for this counseling? Will physicians use traditional office visit codes (e.g., 99212-99215) for these sessions? Will they code based on the time spent counseling? It is important that Medicare addresses related billing and coding issues for several reasons. The first is that this is work that should and must occur in physicians’ offices. Secondly, it does take time and should be compensated.

How much documentation will be required? Coding and billing will demand documentation, as with other services covered and paid by Medicare. However, this should not be another Medicare paperwork burden for physicians. Unrealistic time and/or documentation requirements as part of the coverage for counseling on smoking cessation may doom effective provision of the benefit.

In asking these questions, we are not qualifying our support for the basic Medicare decision to cover smoking cessation counseling. Rather, we are simply indicating that Medicare’s decision in this instance raises additional decision points that we anticipate CMS will address through payment policy and other means. If we may be of any assistance in this regard, please let us know.

Thank you for the opportunity to comment on this proposed coverage policy. If you or your staff has any questions about this matter, please let us know.

Sincerely,

Michael Fleming, MD

Cc:

Marcel Salive, MD, MPH (CMS)
William Larson (CMS)
Jyme Schafer, MD, MPH (CMS)
Clay Farris (CMS)