Primary Care Coding Alert

This truth plan reveals 99406, 99407 minimum requirements to avoid overwork.

With American Heart Month under way, you-ve got to get your stop-smoking counseling documentation down pat or risk paybacks.

Now that 99406 and 99407 are no longer new codes, some payers are creating policies on the codes- requirements. Bust these myths regarding coding for stop-smoking counseling to make sure your practice's expected reimbursement does not go up in smoke.

Myth 1: You Need a Plan and Referral to Support 99406, 99407

-Last year, I was told as long as the doctor noted he advised on the risks, advised the patient to quit, gave an Rx, it would support 99406,- recalls Kathleen Goodwin, coding coordinator at LaPorte Regional Physicians Network in Indiana. -How much documentation is needed to support 99406, which is for 3-10 minutes of smoking cessation counseling, and 99407, which is for more than 10 minutes of counseling?- she asks.

This year the documentation requirements seem to have gotten greater, notes Goodwin. Indiana Medicaid requires the above plus time, an action plan, patient's readiness to quit, and registering at the Indiana Tobacco Hotline (1.800.Quit.Now). -It seems like a lot of work for the doctors,- she adds.

Truth: An action plan and referral are not CMS's national requirements for reporting smoking counseling cessation. -I have been through all the transmittals and MLN Matters,- and none specify that the counseling must include a plan for the patient to quit and a referral to a treatment center, says Karen K. Byrne, RN, BS, CPC, CEMC, Coding Analyst for the 70-physician Carolina Health Specialists in Myrtle Beach, S.C.

The Medicare National Coverage Determinations Manual (Section 210.4) and Medicare Claims Processing Manual (Chapter 32, Section 12.6- Post-Payment Review for Smoking and Tobacco-Use Cessation Counseling Services)-do not require that covered counseling must include a plan for the patient to quit, and a referral to a treatment center,- confirms Bill Larson, MA, lead analyst for CMS's coverage and analysis group.

Myth 2: You Need a Lot of Documentation

In 2008, one physician recalls he would report 99406 or 99407 if he discovered a patient smoked or dipped, recorded the patient's frequency use, motivated him to stop, and set some goals for the patient to reduce or quit using tobacco or snuff. This year some insurers have published guides on the steps smoking cessation involves.

For instance, Indiana Medicaid pays $22.08 per unit of S9075 (Smoking cessation treatment) with a primary diagnosis of 305.1 (Tobacco use disorder) and details tobacco cessation guidelines- five steps:
- Ask patients about tobacco use
- Strongly advise quitting
- Assess tobacco use/readiness to quit.
- If the patient is ready to quit, the physician refers the patient to the Indiana Tobacco Quitline using a fax form. For patients who are not ready to quit, the guideline suggests promoting motivation using the 5 Rs of intervention (relevance, risks, rewards, roadblocks, repetition) for patients not ready to quit. If the patient does not currently use tobacco, the physician can prevent relapse (if the patient recently used tobacco) or encourage continued abstinence.
- Prescribe pharmacotherapy, which includes assessing the patient's history of tobacco use, discussing medication options, facilitating the quitting process, and evaluating the patient's quit attempt at follow-up.

The Indiana Tobacco Control Center seems to have developed these recommendations but does not indicate that documentation must detail each item. You would expect a physician to note the spirit of the items, which seem to be in line with CPT's clinical examples that include questioning, assessing, motivating, and goal setting as follows:

Example: -A 48-year-old smoker with hypertension and obesity receives a tobacco cessation behavioral intervention,- from CPT Changes 2008 -- An Insider's View. 

The AMA described 99406's procedure as:

the qualified health care professional has assessed the readiness to change as positive after a separately reported evaluation and management service. 
The qualified health care professional discusses specific methods to address barriers to change and avoid relapse. The physician assists by prescribing pharmacologic interventions and refers the patient to community support groups. The visit is documented.
The qualified health care professional congratulates the patient for pursuing tobacco cessation and asks the staff to schedule a short interval follow-up visit in two weeks to provide encouragement and additional counseling in order to reduce resumption of smoking.

What Medicare wants: Larson points out, -Section 12.6 of Chapter 32 of the Medicare Claims Processing Manual, however, does provide that -Providers must keep patient record information on file for each Medicare patient for whom a Smoking and Tobacco-Use Cessation Counseling claim is made. These medical records can be used in any post-payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.--

Myth 3: Covered Dx = Year-Round Coverage

If you expect Medicare to pay 99406 or 99407 when the patient meets Medicare's diagnoses requirements (1. currently using tobacco or tobacco products, and 2. either has a disease adversely affected by smoking or requires medication which smoking is a contraindication for), you-re in for an unpleasant surprise. Just because a patient meets the criteria for 99406 and 99407 coverage does not mean you-ll get any smoking cessation counseling session paid.

Truth: Nationally, Medicare has a frequency limitation on 99406 and 99407. If you-re receiving duplicate denials, make sure the patient has not exceeded these benefits:

- Year 1: Two attempts in a 12-month period. -Each attempt may include a maximum of four counseling sessions.- What it is: A qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. So a beneficiary may receive eight smoking and tobacco-use cessation counseling sessions in a 12-month period.

- Year 2: Another eight counseling sessions during a second or subsequent year after 11 full months have passed since the first Medicare-covered cessation counseling session was performed. For example, if the first of eight covered sessions was performed in April 2008, a second series of eight sessions may begin in April 2009.