Coding Reference

In 2014, the Affordable Care Act (ACA) requires insurance plans to cover many clinical preventive services(www.healthcare.gov). Some of the covered preventive services include: 1. tobacco use screening for all adults; 2. tobacco cessation counseling for adults who use tobacco, and expanded counseling for pregnant women.

Medicare

Counseling

Medicare Part B covers two levels of tobacco cessation counseling for symptomatic and asymptomatic patients: intermediate and intensive.

Two cessation attempts are covered per year, and both coinsurance and deductible are waived. Each attempt may include a maximum of four intermediate or intensive counseling sessions. The total annual benefit covers up to eight smoking cessation counseling sessions in a 12-month period. The patient 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.

To qualify for payment from Medicare, the following criteria must be met at the time of service:

  • Patients must be competent and alert
  • Counseling must be provided by a physician or other Medicare-recognized practitioner

Symptomatic Patients

Use the following CPT codes for patients who use tobacco and have been diagnosed with a recognized tobacco-related disease or exhibit symptoms consistent with tobacco-related disease:

 

Code Type of Counseling Description
Code : 99406Type of Counseling : IntermediateDescription: Smoking and tobacco use cessation counseling visit greater than 3 minutes but not more than 10 minutes
Code : 99407Type of Counseling : IntensiveDescription: Smoking and tobacco use cessation counseling visit greater than 10 minutes

 

Asymptomatic Patients

Use the following CPT codes for patients who use tobacco but do not have symptoms of tobacco-related disease:

CodeType of CounselingDescription
Code: G0436Type of Counseling: IntermediateDescription: Smoking and tobacco use cessation counseling visit greater than 3 minutes but not more than 10 minutes.
Code: G0437Type of Counseling: IntensiveDescription: Smoking and tobacco use cessation counseling visit greater than 10 minutes.

 

  • The ICD-9 CM codes 305.1 (nondependent abuse of drugs; tobacco use disorder; tobacco dependence) and/or V15.82 (history of tobacco use) should be used with the above CPT codes.
  • For counseling less than 3 minutes in length, service is considered as bundled into the appropriate evaluation and management (E/M) visit code and should not be reported separately.
  • Tobacco cessation codes can be used separately or along with E/M codes (99201-99215). However, a -25 modifier should be appended to the E/M code. When tobacco cessation codes are billed with E/M codes, E/M services have to be provided on the same day and separately identifiable from smoking cessation counseling.

*For each patient receiving smoking and tobacco use cessation counseling or counseling to prevent tobacco use, medical record documentation must show and must include standard information along with sufficient patient history  to adequately demonstrate that Medicare coverage conditions were met.

Medications

Medicare Part D covers FDA-approved cessation drug therapies. However, over-the-counter therapies are typically excluded.

Medicaid

Counseling

Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients. However, providers are encouraged to contact their state Medicaid office for coverage information in their specific state.

Medications

As of January 1, 2014, all state Medicaid programs are required to support all FDA-approved smoking cessation medications without requiring co-pays or other financial barriers.

Private/Commercial Insurance Carriers

Private insurers are required to provide evidence-based tobacco cessation counseling and interventions to all adults and pregnant women. Private payer benefits are subject to specific plan policies. Providers need to check with insurance plans to determine what specific interventions are included and the extent to which they are covered.

HCPCS/CPT CodeType of CounselingDescription
HCPCS/CPT Code: 99406Type of Counseling: IntermediateDescription: Smoking and tobacco use cessation counseling visit greater than 3 minutes but not more than 10 minutes (Short Descriptor: Smoke/tobacco counseling 3-10)
HCPCS/CPT Code: 99407Type of Counseling: IntensiveDescription: Smoking and tobacco use cessation counseling visit greater than 10 minutes (Short Descriptor: Smoke/tobacco counseling greater than 10)
HCPCS/CPT Code: S9075Type of Counseling: Smoking Cessation TreatmentDescription:  
HCPCS/CPT Code: S9453Type of Counseling: Smoking Cessation Classes (non-physician provider, per session)Description:  
HCPCS/CPT Code: 99381-99397Type of Counseling: Preventive Medicine ServicesDescription:  
HCPCS/CPT Code: 99078Type of Counseling: Physician Educational Services in Group SettingDescription:  

Various E/M services (associated with acute or chronic care) may be coded. When providing an E/M service, if greater than 50% of face-to-face time with patient is spent on counseling, time may be used as basis for selection of level of service.


ICD-9 Diagnosis CodeDescription
ICD-9 Diagnosis Code: 305.1Description: Tobacco use disorder
ICD-9 Diagnosis Code: 649.0xDescription: Tobacco use disorder complicating pregnancy, childbirth, or puerperium
ICD-9 Diagnosis Code: 989.84Description: Other substances, chiefly nonmedicinal as to source, tobacco*
  • List additional code to specify nature of toxic effect. Excludes localized toxic effects classified elsewhere and respiratory conditions due to external agents and, if applicable, any diagnosis code(s) for condition(s) evaluated and managed in the same encounter.*
  • All codes with .x or .xx require fourth or fifth digits. See the ICD-9 manual for complete descriptions.

*This list was formulated based on the 2004 Surgeon General's Report on the Health Consequences of Smoking. It is not an all-inclusive list and may be subject to different interpretation of the report.

Self-pay Patients and Uninsured Patients

Resources for patients who do not have insurance coverage or who have limited coverage by their insurance carrier include the following:

  • Quitlines (1-800-QUITNOW)
  • Online cessation resources
  • Flexible spending accounts if smoking cessation is an allowable expense
  • Employee Assistance Programs (EAP); tobacco cessation may be covered by EAPs  in some cases.
  • Community resources and support groups
  • Out-of-pocket spending