EM Coding Alert

Consider using G0436 or G0437 when making your coding decision.

Coding smoking and tobacco use counseling sessions may be cut and dry, but throw in a medical condition resulting from tobacco use and things get more complicated.

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

Code the Straight Forward

Scenario #1: An established patient comes in for a problem-related visit (cough, sinus infection, 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 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 versus 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 rectal cancer. 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. 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 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) and be paid 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: Most 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 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 tobaccorelated condition came into 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: Yes, you can use 99406 or 99407, but there are two other codes that better fit your situation. 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).

CPT® codes G0436 or G0437 are appropriate to report for preventive counseling. Use codes 99406 or 99407 when you have a payer that does not follow Medicare guidelines or when you have an asymptomatic Medicare patient that you are counseling therapeutically.