Oncology & Hematology Coding Alert

Question: How do we code for smoking cessation counseling? What are the criteria used to determine coverage?

New York Subscriber

Answer: Many payers provide coverage for tobacco-use cessation counseling. For Medicare Part B, and those who follow its rules, proper coding depends on whether the patient has signs or symptoms of tobacco-related disease.

For a patient diagnosed with or showing signs/symptoms of a tobacco-related disease, you should report one of the following to Medicare, based on the length of the individual session:

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

For asymptomatic patients, Medicare provides two different codes for counseling:

• G0436, Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
• G0437, ... intensive, greater than 10 minutes.

Medicare requires one of the following diagnosis codes to accompany the G codes:

• 305.1, Nondependent tobacco use disorder
• V15.82, Personal history of tobacco use.

Important: For those payers who don't accept Medicare G codes, you should report 99406 or 99407 regardless of whether the patient is symptomatic.

Coverage for counseling includes two attempts at cessation. In each attempt, four counseling sessions will be covered (for a total of eight sessions in one year). Once a person receives a total of eight sessions in one year, coverage won't be available until a year has passed since the first session. As Medicare states: "In calculating a 12-month period, 11 months must pass following the month in which the 1st Medicare covered cessation counseling session was performed" (Transmittal 2058, CR 7133, www.cms.gov/transmittals/downloads/R2058CP.pdf).

Tip: The following are additional criteria for tobacco-use cessation counseling coverage:

• The person who receives counseling should be alert and competent when the sessions are provided
• The counseling to the person should be performed only by a qualified physician or a practitioner who is recognized by Medicare to provide these services.

For more information: CMS offers a brochure at www.cms.gov/mlnproducts/downloads/smoking.pdf.