Coding Reference

In 2014, the Patient Protection and Affordable Care Act (ACA) began requiring isurance plans to cover many clinical preventive services(www.healthcare.gov). Two of the covered preventive services include:

  • Tobacco use screening for all adults and adolescents
  • Tobacco cessation counseling for adults and adolescents who use tobacco, and expanded counseling for pregnant women

Government Payors

Medicare

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

Two cessation attempts are covered per 12-month period. Each attempt may include a maximum of four intermediate or intensive counseling sessions. Therefore, 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 once 11 full months have passed since the first Medicare-covered cessation counseling session took place.

For counseling to qualify for Medicare payment, the following criteria must be met at the time of service:

  • Patients must be competent and alert at the time of the counseling is provided.
  • Counseling must be provided by a physician or other Medicare-recognized health care professional.

Symptomatic Patients

Symptomatic patients are those who use tobacco and:

  • Have been diagnosed with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use.
  • Take a therapeutic agent for which the metabolism or dosing is affected by tobacco use, based on information approved by the U.S. Food and Drug Administration (FDA).

Both cosinsurance and deductible apply.

Use the following codes for symptomatic patients.

HCPCS/CPT Code Type of Counseling Description
HCPCS/CPT Code : 99406Type of Counseling : IntermediateDescription: Smoking and tobacco use cessation counseling visit is greater than three minutes, but not more than 10 minutes
HCPCS/CPT Code : 99407Type of Counseling : IntensiveDescription: Smoking and tobacco use cessation counseling visit is greater than 10 minutes
ICD-9 CM Diagnosis Code Description
ICD-9 CM Diagnosis Code : 305.1
Description: Tobacco use disorder
ICD-9 CM Diagnosis Code : 649.0xDescription: Tobacco use disorder complicating pregnancy, childbirth, or peurperium
ICD-9 CM Diagnosis Code : 989.84Description: Toxic effect of tobacco
ICD-10 CM Diagnosis Code Description
ICD-10 CM Diagnosis Code : F17.200
Description: Nicotine dependence, unspecified, uncomplicated
ICD-10 CM Diagnosis Code : F17.201Description: Nicotine dependence, unspecified, in remission
ICD-10 CM Diagnosis Code : F17.210Description: Nicotine dependence, cigarettes, uncomplicated
ICD-10 CM Diagnosis Code : F17.211Description: Nicotine dependence, cigarettes, in remission
ICD-10 CM Diagnosis Code : F17.220Description: Nicotine dependence, chewing tobacco, uncomplicated
ICD-10 CM Diagnosis Code : F17.221Description: Nicotine dependence, chewing tobacco, in remission
ICD-10 CM Diagnosis Code : F17.290Description: Nicotine dependence, other tobacco product, uncomplicated
ICD-10 CM Diagnosis Code : F17.291Description: Nicotine dependence, other tobacco product, in remission

 

Asymptomatic Patients

Asymptomatic patients are those who use tobacco but do not have symptoms of tobacco-related disease.

Both coinsurance and deductible are waived.

Use the following CPT codes for asymptomatic patients.

HCPCS/CPT CodeType of CounselingDescription
HCPCS/CPT Code: G0436Type of Counseling: IntermediateDescription: Smoking and tobacco use cessation counseling visit greater than three minutes, but not more than 10 minutes.
HCPCS/CPT Code: G0437Type of Counseling: IntensiveDescription: Smoking and tobacco use cessation counseling visit is greater than 10 minutes.
ICD-9 CM Diagnosis Code Description
ICD-9 CM Diagnosis Code : 305.1
Description: Tobacco use disorder
ICD-9 CM Diagnosis Code : V15.82
Description: Personal history of tobacco use
ICD-10 CM Diagnosis Code Description
ICD-10 CM Diagnosis Code : F17.200
Description: Nicotine dependence, unspecified, uncomplicated
ICD-10 CM Diagnosis Code : F17.201Description: Nicotine dependence, unspecified, in remission
ICD-10 CM Diagnosis Code : F17.210Description: Nicotine dependence, cigarettes, uncomplicated
ICD-10 CM Diagnosis Code : F17.211Description: Nicotine dependence, cigarettes, in remission
ICD-10 CM Diagnosis Code : F17.220Description: Nicotine dependence, chewing tobacco, uncomplicated
ICD-10 CM Diagnosis Code : F17.221Description: Nicotine dependence, chewing tobacco, in remission
ICD-10 CM Diagnosis Code : F17.290Description: Nicotine dependence, other tobacco product, uncomplicated
ICD-10 CM Diagnosis Code : F17.291Description: Nicotine dependence, other tobacco product, in remission
ICD-10 CM Diagnosis Code : Z87.891
Description: Personal history of nicotine dependence

Medicaid

Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients. For example, the ACA requires states to expand Medicaid coverage of cessation services for pregnant women. You are encouraged to contact your state Medicaid office for coverage information in your specific state.

The Centers for Medicare and Medicaid Services encourage state partners to support smoking cessation by ensuring coverage of all FDA-approved smoking cessation medication (prescription and over-the-counter [OTC]) without a copayment requirement or other financial barrier.


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. Check with individual insurance plans to determine what specific interventions are included and the extent to which these interventions are covered.

HCPCS/CPT CodeType of CounselingDescription
HCPCS/CPT Code: 99406Type of Counseling: IntermediateDescription: Smoking and tobacco use cessation counseling visit is greater than three minutes, but not more than 10 minutes
HCPCS/CPT Code: 99407Type of Counseling: IntensiveDescription: Smoking and tobacco use cessation counseling visit is greater than 10 minutes
HCPCS/CPT Code: S9075Type of Counseling: Smoking cessation treatmentDescription:  
HCPCS/CPT Code: S9453Type of Counseling: Smoking cessation classesDescription: Non-physician provider, per session
HCPCS/CPT Code: 99381-99397Type of Counseling: Preventive medicine servicesDescription: Comprehensive, preventive evaluation based on age and gender to include appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and related plan of care.
HCPCS/CPT Code: 99078Type of Counseling: Physician educational servicesDescription: Group setting (e.g., prenatal, obesity, diabetes)
Suggested Tobacco-related ICD-9 CM Diagnosis CodesDescription
Suggested Tobacco-related ICD-9 CM Diagnosis Codes: 305.1Description: Tobacco use disorder
Suggested Tobacco-related ICD-9 CM Diagnosis Codes: 649.0xDescription: Tobacco use disorder complicating pregnancy, childbirth, or puerperium
Suggested Tobacco-related ICD-9 CM Diagnosis Codes: 989.84Description: Toxic effect of tobacco

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: