Question: I read -Put an End to Tobacco Cessation Questions- in the July issue, which says not to report G0375-G0376 for inpatient counseling when the primary ICD-9 code is 305.1 (Tobacco use disorder) because the diagnosis doesn't medically justify the service. Do the same principles apply to outpatient counseling sessions regarding the diagnosis code rules? Does a patient have to have a primary diagnosis of cancer, or is V65.42 (Counseling on substance use and abuse) sufficient?
Texas Subscriber
Answer: You should always report the diagnosis codes supported by your documentation, but if you don't report a condition that makes the counseling medically necessary, such as lung cancer, you-re unlikely to get paid.
Here's why: One of the conditions for coverage is that the patient must either have a disease or an adverse health effect that the U.S. Surgeon General links to tobacco use or take a therapeutic agent whose metabolism or dosing is affected by tobacco, according to the National Coverage Determination for tobacco use cessation counseling (
www.cms.hhs.gov/Transmittals/downloads/R36NCD.pdf).
The diagnosis codes you report should reflect either that condition adversely affected by tobacco or the condition requiring the drug affected by tobacco, according to the Medicare Claims Processing Manual (
www.cms.hhs.gov/Transmittals/downloads/R562CP.pdf).
And you need documentation of that condition if Medicare comes calling for proof.
Note: The NCD specifically states that for inpatients, CMS -will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient's hospital stay.- CMS doesn't offer any instruction about primary diagnosis codes for outpatient services.