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 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:
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:
Use the following CPT codes for patients who use tobacco but do not have symptoms of tobacco-related disease:
*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.
Medicare Part D covers FDA-approved cessation drug therapies. However, over-the-counter therapies are typically excluded.
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.
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 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.
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.
*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.
Resources for patients who do not have insurance coverage or who have limited coverage by their insurance carrier include the following:
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Tobacco Prevention & Cessation
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