Cardiology Coding Alert

Decipher the math involved in counting covered sessions.

A variety of factors influence how you report smoking and tobacco use counseling sessions, including time, setting, and payer.

Take a look at these three case studies provided by readers to ensure your cessation counseling coding is on the right track.

Code the Counseling/Problem Visit Combo

Scenario 1: An established patient comes in for a problem-related visit (chest pain, etc.). The documentation supports an expanded problem-focused history, expanded problem-focused exam, and low complexity medical decision making (MDM). During the visit, the physician reviews the patient's history, and the patient says he is still smoking. After a discussion about the problem the patient presented for and possible treatments, the physician tells the patient that if he attempts to quit smoking, the treatment plan will be more effective. The patient agrees to look into this, and the smoking cessation counseling commences. How should I code this encounter?

Answer: You should first report 99213 (Office or other outpatient visit for the evaluation and management of an established patient...) for the problem-related visit based on the history, exam, and MDM your provider documented. Then report 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (... intensive, greater than 10 minutes) for the smoking cessation counseling, says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations at Allegheny Health Network in Pittsburgh, Pa. The time spent counseling the patient must be fully documented, and you will select 99406 or 99407 depending on the time your physician spent on the counseling.

Don't miss:You will attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service when billing 99406 or 99407 to let your payer know your providers deserve separate payment for both the E/M and the counseling service.

Admitted patient: If the patient is in the hospital, Medicare will cover your provider's counseling for smoking cessation. The catch is that Medicare will only cover patients in the hospital if the counseling is not the primary reason for the hospital stay.

Example: Your patient has surgery related to his heart rhythm disorder. While in the hospital your physician spends six minutes on smoking cessation counseling. You can report 99406 for the encounter.

Identify Issues Behind Denial

Scenario 2: I submit 99407 with 99213, and I'm getting denials. I attach modifier 25 to 99213 but the denials seem to be asking for a modifier on the 99407. What modifier should I use?

Answer: Assuming the documentation supports billing both the E/M service and the cessation counseling, you will attach modifier 25 to 99213 and should receive payment for 99213 and 99407.

The issue you are having may relate to the number of sessions or the lack of a diagnosis code that shows medical necessity for both services. Your documentation should illustrate the need for the counseling and then the appropriate diagnosis code to support the counseling. Session limits: Many payers will pay for eight smoking and tobacco-use cessation counseling sessions per year.

In a second or subsequent year, the patient may receive another eight sessions. This second set of eight sessions will start 11 months after the first initial session.

Example: One of your physician's patients starts the first of his eight sessions in January 2015. The 11-month waiting period starts in February 2015. In January 2016, the patient can receive a second set of eight sessions, no matter when he finishes his first set.

"CMS allows for two individual tobacco cessation counseling attempts per year, with a maximum of four sessions (intermediate or intensive) per attempt," says Betty A. Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, director, ICD-10 Development and Training at the AAPC in Salt Lake City.

Documentation: Your physician needs to fully document the counseling and the time spent with the patient in case your payer asks to see the note.

From a Medicare standpoint, CMS covers tobacco use prevention counseling for outpatient and hospitalized Medicare beneficiaries as long as the session meets the following criteria:

• Patient uses tobacco (regardless of whether he has signs or symptoms of tobacco-related disease)
• Patient is competent and alert at the time the counseling is provided
• A qualified physician or other Medicare-recognized practitioner performs the counseling.

Read more: Refer to MLN Matters article MM7133 "Counseling to Prevent Tobacco Use" at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7133.pdf for more details.

Diagnosis: The diagnosis code on smoking and tobacco cessation counseling services claims needs to:

• Reflect the patient's condition that tobacco use is adversely affecting
• Reflect the condition the physician is treating with a therapeutic agent where tobacco use is affecting its metabolism or dosage.
• Consider Other Code Options

Scenario 3: A patient with no symptoms of a tobacco-related condition came in to see his doctor for smoking cessation counseling, and I reported 99406 with the office visit. Is this the correct code for his counseling?

Answer: You may be able to use 99406 or 99407 depending on your payer, but there are two other codes that better fit your situation when reporting to Medicare. Use G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) or G0437 (...intensive, greater than 10 minutes).

Codes G0436 or G0437 are appropriate to report for preventive counseling. Be sure to add 305.1 (Nondependent tobacco use disorder) or V15.82 (Personal history of tobacco use) to support your claim.

Use codes 99406 or 99407 when you have a payer that does not follow Medicare guidelines or when you have a symptomatic Medicare patient who you are counseling therapeutically.