Part B Insider (Multispecialty) Coding Alert

Find out when it's appropriate to attach modifier 25

Tobacco-use counseling can benefit smokers, but you have to make sure that your physicians get the compensation they deserve from Medicare. Here's the scoop on how to choose codes that will translate into proper payment.

Good news: CMS began covering the counseling visits in March of last year. 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 visits the physician provides.

This is an excellent coverage decision, says Beverly Roy, CPC, CCP, an internal-medicine coder at Summit Medical Associates in Hermitage, TN. "Our physicians are always counseling patients with heart disease and lung cancer about quitting, and they deserve to get paid for what they do."

1. Don't Let Frequency Limits Confuse You

Important: 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, FL. 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 internists 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 initiates a counseling attempt on a Medicare patient with heart disease, which the physician has linked to the beneficiary's lifelong smoking. During the month, the physician holds four sessions. Each session lasted more than 10 minutes, so you could report the first attempt as G0376 x 4. Then, the physician starts a second attempt with the same patient. This time the physician bills for three intermediate sessions and for one intensive. You should report G0375 x 3 and G0376 x 1.

Heads-up: If the session lasts less than three minutes, you should include that time with the appropriate E/M code ( CPT 99201 - 99215 ), Roy says.

2. Be Selective With Your Diagnosis Codes

When choosing an ICD-9 code, you should report one that represents either of the following:

• The condition that the smoking or tobacco-use is "adversely affecting," Witkin says. For instance, in the scenario above, you could list 429.1 (Myocardial degeneration) for the heart disease, depending on the physician's documentation.

Other possible diagnoses include chronic obstructive pulmonary disease (491.21, Decompensated obstructive bronchitis and emphysema), lung cancer (162.0-162.9, Malignant neoplasm of trachea, bronchus, and lung ...) and smoker's cough (491.0, Simple chronic bronchitis). But you can't report G0375 and G0376 when the physician counsels a smoker who doesn't have a disease, Witkin says.

• The illness or disease that the physician is treating with a "therapeutic agent" and the patient's tobacco use is affecting the agent's metabolism or dosage.

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.
 
3. Understand The 'Incident-To' Billing Rules

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 and clinical psychologist may provide the counseling incident-to the physician. Other staff, such as a licensed practical nurse, may not, Witkin says.

4. Report Appropriate E/M Visits

Medicare also allows you to report an E/M visit ( CPT 99201 - 99215 ) in addition to the tobacco-counseling if you attach 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.

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 out-patient visit ... established patient ...), with modifier 25.