Oncology & Hematology Coding Alert

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.