Primary Care Coding Alert

Consider between using HCPCS codes and CPT® codes appropriately.

You may think that reporting a smoking and tobacco use counseling session is very simple and straightforward, but if there is a medical condition resulting from tobacco use, things might be more complicated.

Take a look at these three case studies provided by readers and ensure your cessation counseling coding is on the right track.

Code the Straight Forward

Scenario #1: An established patient comes in for a problem-related visit (cough, sinus infection, etc.). The documentation supports an expanded problem-focused history, expanded problem-focused exam, and low complexity medical decision making (MDM). During the visit, your physician reviews the patient’s history, and the patient says he is still smoking. After a discussion about the problem and possible treatments, your physician tells the patient that if he attempts to quit smoking, the treatment plan will be more effective. The patient agrees to look into this and the smoking cessation counseling commences. How should I code this encounter?

Answer: You should first report 99213 (Office or other outpatient visit for the evaluation and management of an established patient...) for the problem-related visit based on the history, exam, and MDM your provider documented. Then report 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (... intensive, greater than 10 minutes) for the smoking cessation counseling, says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, director of coding operations at Allegheny Health Network in Pittsburgh, Pa. The time spent counseling the patient must be fully documented, and you will select 99406 versus 99407 depending on the time your physician spent on the counseling.

Don’t miss: You will attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the problem-oriented E/M service (99213 in this case) when also billing 99406 or 99407 to let your payer know your providers deserve separate payment for both the problem-oriented E/M and the counseling service.

Admitted patient: Per section 210.4.C of Medicare’s National Coverage Determination Manual, if the patient is in the hospital, Medicare will cover your provider’s counseling for smoking cessationonly if Tobacco Use Disorder is not the principal diagnosis. CMS does not consider inpatient hospital stays with the principal diagnosis of Tobacco Use Disorder to be reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, Medicare will not cover tobacco cessation services if tobacco cessation is the primary reason for the hospital stay.

Identify Issues Behind Denial

Scenario #2: I submit 99407 with 99213, and I’m getting denials. I attach modifier 25 to 99213, but the denials seem to be asking for a modifier on the 99407. What modifier should I use?

Answer: Assuming the documentation supports billing both the E/M service and the cessation counseling, you will attach modifier 25 to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) and should be paid for both 99213 and 99407, assuming all other coverage criteria are met.

The issue you are having may relate to the number of sessions or the lack of a diagnosis code that shows medical necessity for both services. Your documentation should illustrate the need for the counseling and then the appropriate diagnosis code to support the counseling. 

Session limits: Like Medicare, many other payers will only pay for a limited number (e.g. eight) of smoking and tobacco-use cessation counseling sessions per year or 12-month period.

In a second or subsequent year/12-month period, the patient may receive additional sessions beyond the yearly limit. However, if the number of sessions exceeds the payer’s maximum allowable in a given time period, sessions over and above the maximum will be denied, even with the proper use of modifiers. For Medicare, at least 11 months must have elapsed after the month of the first session before the limit resets.

Example: One of your FP’s Medicare patients starts the first of his eight sessions in January 2015. Medicare will allow up to seven more sessions during 2015. If the patient has a ninth or subsequent session during 2015, Medicare will deny coverage of it. The 11-month waiting period starts in February 2015 and ends in December 2015, such that, in January 2016, the patient can receive a second set of eight sessions, no matter when he finishes his first set.

“CMS allows for two individual tobacco cessation counseling attempts per year, with a maximum of four sessions (intermediate or intensive) per attempt,” says Betty A. Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, director, ICD-10 Development and Training at the AAPC in Salt Lake City.

Documentation: Your physician needs to fully document the counseling and the time spent with the patient in case your payer asks to see the note.

Diagnosis: The diagnosis code on smoking and tobacco cessation counseling services claims needs to:

• Reflect the patient’s condition that tobacco use is adversely affecting

• Reflect the condition the physician is treating with a therapeutic agent where tobacco use is affecting its metabolism or dosage.

Consider Other Code Options

Scenario #3: A patient with no symptoms of a tobacco related condition came into to see his doctor for smoking cessation counseling, and I reported 99406 with the office visit. Is this the correct code for his counseling?

Answer: Yes, you can use 99406 or 99407, unless the patient is a Medicare patient. For Medicare, there are two other codes that better fit your situation. Use G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) or G0437 (... intensive, greater than 10 minutes).

CPT® codes G0436 or G0437 are appropriate to report for preventive counseling. Use codes 99406 or 99407 when you have a payer that does not follow Medicare guidelines or when you have an asymptomatic Medicare patient that you are counseling therapeutically.

From a Medicare standpoint, CMS covers tobacco use prevention counseling for outpatient and hospitalized Medicare beneficiaries as long as the session meets the following criteria:

• Patient uses tobacco (regardless of whether he has signs or symptoms of tobacco-related disease)

• Patient is competent and alert at the time the counseling is provided

• A qualified physician or other Medicare-recognized practitioner performs the counseling.

“From a CPT® perspective, codes 99406 and 99407 may be used for either preventive or therapeutic counseling; it is the diagnosis code that distinguishes the purpose of the counseling,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “In comparison, CMS uses G0436 and G0437 to distinguish preventive counseling from therapeutic counseling, which it attributes to 99406 and 99407; in essence, CMS uses the procedure code, not just the diagnosis, to distinguish the nature of the counseling,” Moore adds. 

Read more: Refer to MLN Matters article MM7133 “Counseling to Prevent Tobacco Use” at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7133.pdf for more details.