EM Coding Alert

See what info our pro says physicians should include in 99406 and 99407 documentation.

Smoking is the leading cause of preventable death, according to the Centers for Disease Control and Prevention (CDC). And, in a 2015 report, the CDC noted that nearly 7 out of 10 adult smokers in the United States expressed a desire to completely quit smoking.

If the physicians in your practice are providing smoking and tobacco-use cessation counseling to help patients stop smoking or using tobacco products, don’t forget you can bill for these services.

Read on to learn how you would correctly report the smoking and tobacco-use cessation counseling codes.

Learn Characteristics of Behavior Change Intervention Services

The 2017 CPT^® manual categorizes the codes for smoking and tobacco-use cessation counseling under “behavior change intervention services,” which are appropriate for people who exhibit behavior that is often considered an illness within itself. The manual specifically names tobacco use and addiction, substance abuse/misuse, and obesity as types of this behavior.

Take a look at the choices the CPT^® manual gives you for reporting smoking and tobacco-use cessation counseling:

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes)
• 99407 (… intensive, greater than 10 minutes).

According to the CPT^® manual, you can report behavior change services such as 99406 and 99407 when the physician performs the services as part of treating the patient’s condition(s) that the behavior relates to and can possibly worsen. You can also report behavior change services when the physician performs them to change a patient’s harmful behavior that has not yet caused an illness.

A March 2016 CPT^® Assistant article supplements what the CPT^® manual says about reporting behavior change services.

“Behavior change intervention services involve specific validated interventions of assessing readiness for change and barriers to change; advising a change in behavior; assisting by providing specific suggested actions and motivational counseling; and arranging for services and follow-up,” says CPT^® Assistant.

Reference CMS and CPT^® Guidelines to Understand 99406/99407 Requirements

You can report 99406 and 99407 for outpatient and hospitalized Medicare patients who meet all of the following criteria, according to the CMS Medicare Preventive Services Guide:

• Patients who use tobacco; however, they don’t necessarily have to show signs or symptoms of tobacco-related disease.
• Patients must be competent and alert during counseling.
• Patients should receive counseling from a qualified physician or other Medicare-recognized practitioner.
• Because CMS has determined this is a preventive service, the patient would not incur an out-of-pocket expense by way of co-insurance or deductible.

You can read the Medicare Preventive Services Guide in its entirety here: www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf.

Important: According to the CPT^® manual, you should never report 99407 in conjunction with 99406.

Master Documentation Criteria for 99406 and 99407

To understand what complete documentation for 99406 and 99407 would include, look to the following advice from Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, staff services coordinator/billing/credentialing/auditing/coding at County of Stanislaus Health Services Agency in Modesto, Calif.

The physician should always include the actual time he spent for the session in minutes, according to Johnson. If the session is less than three minutes, the work is already included in the E/M service, and you cannot report it separately.

“The physician should document the conversation in regards to recommendations and prescriptions,” says Johnson. “Include the patient’s history in regards to tobacco use for timeframes [10 years smoker], as well as the frequency in which tobacco is used [two packs per day].”

Takeaway: Key elements in the documentation include the patient’s willingness to quit, prescriptions, time spent, and any handout or educational material the physician provided to the patient, says Johnson.

Check out this example from Johnson showing the information the physician should include when documenting 99406 and 99407: Spent 10 minutes discussing smoking cessation options with patient.  Patient has been a constant smoker for 10 years and is looking to stop. Recommended use of nicotine patches, gum, etc. Provided the patient with a prescription for patches and a pamphlet from the AHA.

Don’t forget: Make sure that you include diagnosis F17.--- (Nicotine dependence…) with all the additional six digits to specify the condition to justify the need for the counseling, says Johnson.

Note: “Some providers also require a condition that is being exacerbated by the smoking such as asthma, COPD [chronic obstructive pulmonary disease], heart disease, etc.,” according to Johnson. “You will need to check with your carriers to determine if these types of requirements exist, as additional diagnosis codes may be needed for payment.”

Ace Reporting 99406 and 99407 with E/M Services

Although you can report 99406 and 99407 separately and in addition to other E/M services the physician performs on the same date, you must make sure the situation fits the guidelines set forth by the CPT^® manual.

According to CPT®, any E/M services the physician reports on the same date as 99406 and 99407 must be distinct, and you must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same say of the procedure or other service). The manual adds that the physician cannot use the time he spent providing the behavior change intervention services as the basis for the E/M code selection.

The Medicare Administrator Contractor (MAC) National Government Services (NGS) adds its own take on this issue: “Medicare will allow payment for a medically necessary E/M service on the same date as tobacco cessation counseling, provided it is clinically appropriate and medically necessary,” says NGS. “Such E/M service should be reported with modifier 25 to indicate it is separately identifiable from the tobacco use service.”