Modifier Coding Alert

Question: How should I bill for “smoking cessation” counseling (99406-99407) with 99214? Medicare denies my E/M code and only pays for the 99406 or 99407. How do I rectify this problem?

Mississippi Subscriber

Answer: You should consider using 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) on the 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) to indicate your physician performed a separately identifiable and billable E/M service in addition to the smoking cessation counseling. Then you should receive separate payment for 99214 and 99406-99407 (Smoking and tobacco use cessation counseling visit; intermediate,…).

Always keep in mind to check with your local payer to make certain this is why your claim is not being paid. Modifier 25 may not be needed, as other information is being requested/required for paying this type of claim.

Critical: Do not just add modifier 25 to get paid. The documentation must support a separately identifiable service that warrants reporting both an E/M code and the 99406-99407 code. 

Example: A teenage patient comes into your office for an E/M visit due to a knee laceration from a skateboard accident. After cleaning the laceration and applying a bandage, your physician performs a 15-minute counseling session to encourage the patient to stop smoking. You should report 99214-25 and 99407, in that order.