New tobacco-use cessation counseling benefits: Three billing scenarios

The Centers for Medicare & Medicaid Services released guidance this week on payment for expanded smoking and tobacco-use cessation counseling. This service is now covered for patients who use tobacco but do not have symptoms of related conditions, and the coverage is retroactive to Aug. 25, 2010. The counseling must be provided by a physician or other qualified health care professional (e.g., physician assistant).

Now for the not-so-good news. Allowing different benefits for the same service based on whether it is preventive or problem-oriented creates coding and payment guidelines that are, well, problem-oriented.

Here's what I mean: While asymptomatic patients became eligible for the counseling benefit on Aug. 25, 2010, the full benefit of the preventive service coverage does not begin until Jan. 1, 2011. For services delivered from Aug. 25, 2010, to Dec. 31, 2010, charges will be subject to any unmet deductible and to the patient's co-insurance. For dates of service Jan. 1, 2011, and after, the same services will not be subject to deductible and co-insurance (i.e., there will be no out-of-pocket expense for the patient who receives the service). This may require some patient education.

Here's what else you need to know to code and bill for these services now and in the future:

• For counseling provided to patients who use tobacco and have a condition that is adversely affected by tobacco use and/or are undergoing a treatment that is adversely affected by tobacco use, continue reporting CPT codes 99406 and 99407. The benefits for these patients have not changed. (If you're not familiar with these services, see the FPM article An Update on Tobacco Cessation Reimbursement.)

• For counseling provided to patients who do not have symptoms of conditions related to tobacco use and are not undergoing a treatment that is adversely affected by tobacco use, report unlisted CPT code 99199, "Unlisted special service, procedure, or report" for dates of service Aug. 25, 2010, through Dec. 31, 2010.  Submit ICD-9 codes 305.1, "Non-dependent tobacco-use disorder," or V15.82, "History of  tobacco use," as well. Be sure to inform patients that unless there is a secondary insurance that pays the balance after Medicare, they may be responsible for an unmet deductible and for co-insurance amounts.

• For counseling provided to asymptomatic patients beginning on Jan. 1, 2011, you should bill using the new Medicare G codes: G0436, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes," or G0437, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes." The same diagnosis codes, 305.1 or V15.82, will be required. Again, patients will not have an out-of-pocket expense for these services when they are delivered on Jan. 1, 2011, or after.

When reporting any significant and separately identifiable evaluation and management service on the same date as tobacco-use cessation counseling, append modifier 25 to the evaluation and management code.

These are some of the first changes for preventive services in response to requirements of the Affordable Care Act. There will no doubt be other guidance coming from CMS and private payers on coverage, coding, and payment for preventive services. Stay tuned, and we will deliver information as promptly as possible after its publication.