Oncology & Hematology Coding Alert

Don't let your G0375-G0376 pay go up in smoke

Tobacco-use counseling can benefit lung-cancer patients, but you have to make sure your oncologists get the compensation they deserve from Medicare.
 
Here's how to keep frequency and incident-to slipups off your claims.
 
The lowdown: CMS began covering counseling visits in March 2005. You should list G0375 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and G0376
(... intensive, greater than 10 minutes) for your oncologist's services.
  
This is an excellent coverage decision, says Beverly Roy, CPC, CCP, a professional coder at Summit Medical Associates in Hermitage, Tenn. The physicians she codes for often counsel patients with lung cancer about quitting, and the doctors deserve to get paid for what they do, she says.

Track the Number of Sessions

Medicare allows two counseling attempts every 12 months. Each attempt includes up to four intermediate or intensive sessions, for a total of eight possible visits in a year, says Leslie Witkin, founder of Physicians First in Orlando, Fla. You can report either an intermediate (G0375) or intensive (G0376) code per session, depending on the amount of time the physician or other qualified provider (such as a physician assistant or nurse practitioner) spent with the patient, she says.
  
-We report G0376 the most often for the first visit because that's when our physicians typically provide the most in-depth counseling,- Roy says. During that first visit, the physician typically addresses the five A-s, she says:
 
1. Ask about tobacco use.
 
2. Advise the patient to quit.
 
3. Assess the willingness to attempt to quit.
 
4. Assist with the attempt to quit.
 
5. Arrange a follow-up for the patient to come back within a week of the quit date.
 
-Because these are time-based codes, I strongly urge physicians to document the amount of time they spent with the patient,- Witkin says. -If you don't document time with the patient, you-ll run into trouble if Medicare audits your records.-
  
Coding scenario: Your physician counsels a Medicare patient with lung cancer. During the month, the physician holds four sessions. Each session lasts more than 10 minutes, so you could report G0376 four times -- once for each session. Then, the physician starts a second attempt with the same patient. This time you report three intermediate sessions (G0375) and one intensive (G0376).
  
Heads-up: If the session lasts less than three minutes, don't report one of the counseling codes. You should include that time with the appropriate E/M code (99201-99215), Roy says.

Be Aware of Diagnosis Code Rules

When choosing an ICD-9 code, you should report the condition that the smoking or tobacco use is harming, Witkin says. For instance, in the scenario above, you could list lung cancer (162.0-162.9, Malignant neoplasm of trachea, bronchus, and lung ...), depending on the physician's documentation.
  
You can't report G0375 and G0376 when the physician counsels a smoker who doesn't have a disease, Witkin says.
 
Watch out: If your physician counsels an inpatient, you can't use G0375 or G0376 if the primary ICD-9 code is 305.1 (Tobacco use disorder) because the diagnosis doesn't medically justify the service, Witkin says. And you shouldn't report G0375-G0376 if tobacco cessation is the primary reason the patient is in the hospital, she adds.

Understand -Incident-To-

If the physician bills the counseling sessions -incident-to,- be sure a qualified practitioner provided the service. 
  
In addition to the physician, a physician assistant, nurse practitioner, certified nurse specialist, or clinical psychologist may provide the counseling incident-to the physician. Other staff, such as a licensed practical nurse, may not, Witkin says.

Report Appropriate E/M Visits

Medicare also allows you to report an E/M visit (99201-99215) in addition to the tobacco counseling if you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, Roy says.
 
Your documentation must be very clear, showing two separate services -- the patient visit and the counseling session.
  
Example: During an encounter, your physician provides five minutes of tobacco-use counseling and treats the patient's two conditions. In this case, you would report G0375 and the appropriate E/M (such as 99213, Office or other outpatient visit for the E/M of an established patient ...), with modifier 25.
 
Remember: These codes describe individual counseling sessions -- not group sessions.
 
Resource: You can find Medicare's National Coverage Determination on smoking cessation at www.cms.hhs.gov/Transmittals/downloads/R36NCD.pdf and a patient bulletin at www.cms.hhs.gov/mlnproducts/downloads/smoking.pdf.