Oncology & Hematology Coding Alert

You can report both HCPCS codes and CPT® codes only if the documentation is clear.

Smoking is a common contributory factor for development of several cancers. Your physician may offer smoking cessation counseling to diverse patients during a preventive or follow-up treatment. You should be watchful for these services as these are easy to miss in your claims. 

Here are three case studies that help you to ensure your cessation counseling coding is on the right track. These scenarios are of different instances when your physician can offer smoking cessation counseling. 

Code the Straight Forward

Case #1: An established patient with lung cancer 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, your physician reviews the patient’s history, and the patient says he is still smoking. After a 10 minute discussion about the problem and possible treatments, your 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) for the smoking cessation counseling. In this example, the time is noted as 10 minutes.  

“In this example, the documentation indicates 10 minutes was spent on this specific counseling service. However, had the time been greater than 10 minutes, the CPT® code 99407 (... intensive, greater than 10 minutes) would be more appropriate,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. The time spent counseling the patient must be specifically documented.  Select from 99406 or 99407 depending on the time your physician spent and documented counseling the patient on the dangers and benefits to cease smoking and tobacco use.

Don’t miss: For the example above, you would also 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 problem-oriented E/M service (99213 in this case) when also billing 99406 or 99407 to let your payer know your providers deserve separate payment for both the problem-oriented E/M and the counseling service.

Admitted patient: Per section 210.4.C of Medicare’s National Coverage Determination Manual, if the patient is in the hospital, Medicare will cover your provider’s counseling for smoking cessation only if Tobacco Use Disorder is not the principal diagnosis. CMS does not consider inpatient hospital stays with the principal diagnosis of Tobacco Use Disorder to be reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, Medicare will not cover tobacco cessation services if tobacco cessation is the primary reason for the hospital stay.

Another example: Your patient has surgery related to his oral cancer. While the patient is in the hospital, your physician spends six minutes on smoking cessation counseling. You can report 99406 for the encounter.

Identify Issues Behind a Denial

Case #2: You submit 99407 with 99213, and face denials. You had attached modifier 25 to the 99213, but the denials seem to be asking for a modifier on the 99407. What modifier should you use?

Answer: “In this scenario, no modifier is needed with 99407,” Loya says. 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 should be paid for both services, assuming all other coverage criteria are met.

Rather than a missing modifier, the issue you are having may relate to the number of sessions or the lack of a diagnosis codes that show medical necessity for both services. Your documentation should illustrate the need for the counseling and then the appropriate diagnosis code to support the counseling.

According to the AAFP (American Academy of Family Practice) the following must be documented in order to bill for codes 99406 & 99407:

• The patient’s tobacco use;

• The patient’s conditions adversely affected by tobacco use or therapeutic agent affected by tobacco use;

• The amount of time spent on tobacco cessation counseling and the context in which it was provided.

Session limits: Like Medicare, many other payers will only pay for a limited number (e.g., eight) of smoking and tobacco-use cessation counseling sessions per year or full 12-month period.

In a second or subsequent year/12-month period, the patient may receive additional sessions beyond the yearly limit. However, if the number of sessions exceeds the payer’s maximum allowable in a given time period, sessions over and above the maximum will be denied, even with the proper use of modifiers. For Medicare, at least 11 months must have elapsed after the month of the first session before the limit resets.

Example: One of your internist’s Medicare patients starts the first of his eight sessions in January 2015. Medicare will allow up to seven more sessions during 2015. If the patient receives a ninth session during 2015, Medicare will deny coverage for the service until full the 11-month benefit period has elapsed.  “At that time, the benefit period resets for the next 12-month period,” Loya says. “If the patient continued on the counseling into the second year, the first visit of the second year is say again in January of 2016, the time subsequent benefit period starts with the month following the first visit of the period, in this case February 2016 and would end in December 2016, such that, in January 2017, the patient can receive a second set of eight sessions, no matter when he finishes his first set and so on.”

Note: “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.

Consider Other Code Options

Scenario #3: A Medicare patient with no symptoms of a tobacco related condition presents to the physician for smoking cessation counseling after a screening for breast cancer. Are you correct in reporting code 99406 with the office visit?

Answer: For Medicare, 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). These codes are appropriate to report for preventive counseling. 

You would use CPT® codes 99406 or 99407 when you have a commercial payer that does not follow Medicare guidelines or when you have an asymptomatic Medicare patient that you are counseling therapeutically.

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.

“From a CPT® perspective, codes 99406 and 99407 may be used for either preventive or therapeutic counseling; it is the diagnosis code that distinguishes the purpose of the counseling,” notes a coding specialist. “In comparison, CMS uses G0436 and G0437 to distinguish preventive counseling from therapeutic counseling, which it attributes to 99406 and 99407; in essence, CMS uses the procedure code, not just the diagnosis, to distinguish the nature of the counseling,” he adds.

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.