Primary Care Coding Alert

CPT® Coding:

Clear Away Confusion Over Smoking Cessation Coding

Published on Fri Sep 15, 2023

See how reporting cessation phone calls differs from in-person.

According to the AMA, approximately 30 to 50 percent of smokers in the US try to quit smoking each year, but only 7.5 percent succeed. The benefits of quitting are clear, but most people need outside help to kick the habit. This is why most primary care practices offer smoking cessation counseling.

As primary care coders, you may have questions about which counseling codes to use and how to accurately report them. If so, don’t quit now; keep reading.

Understand Cessation Counseling Eligibility

Medicare Part B will cover tobacco cessation counseling for outpatient and hospitalized patients who use tobacco, “even if they are not showing signs or symptoms of tobacco-related diseases,” says Denae Merrill, CPC, CDEO, CRC, RADV (risk adjustment data validation) project and training manager in Michigan.

The Centers for Medicare & Medicaid Services’ (CMS’) National Coverage Determination (NCD) on Counseling to Prevent Tobacco Use (https://www.cms.gov/medicare-coverage-database/ view/ncd.aspx?NCDId=342) maintains specific guidelines for the services described by codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (… intensive, greater than 10 minutes). The NCD states that “CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries

Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
Who are competent and alert at the time that counseling is provided; and,
Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.”

Some private payers also cover smoking cessation and often follow Medicare’s lead when it comes to coverage policies, although each payer’s coverage guidelines may include significant or subtle differences from Medicare’s. If ever you’re unsure, check with the payer policy before submitting a claim.

Note: According to CPT^®Assistant Vol 30, Issue 9, if the provider is counseling patients on how to quit vaping, coding remains the same.

Recognize the Differences Between 99406 and 99407

Per the code descriptors, time is the main difference between the two smoking cessation counseling codes. Depending on the circumstances, you may need to report a standard evaluation and management (E/M) code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) in conjunction with or instead of 99406 or 99407.

Why: When you examine the descriptor for 99406, you’ll see the minimum time threshold for counseling is three minutes. If the patient came in specifically to address quitting smoking and the physician provides smoking cessation counseling for more than three minutes, up to 10 minutes, you’ll report 99406. If the PCP spends more than 10 minutes, report 99407.

However, if the patient sees the physician for other reasons and there is also a brief discussion about smoking that occupies fewer than three minutes, then the counseling is covered within the E/M service, and you shouldn’t report it separately. If the physician provides more than just smoking and tobacco use cessation counseling on the same day and the documented work supports reporting an E/M visit, then you’ll append 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 appropriate E/M code to show the E/M service is a separately identifiable service from the cessation counseling, which you’ll report using either 99406 or 99407, depending on time spent.

Note: Only a physician or other qualified healthcare professional recognized by Medicare can bill the agency directly for the service.

Documentation alert: “As with all time-based CPT^®codes, ensure the documentation for 99406 or 99407 includes the time spent providing face-to-face counseling to the patient. Even though the CPT^®code descriptors allow for a range of time, it is advised to document the specific time spent in face-to-face counseling,” says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, AAPC Fellow, senior manager of healthcare services of Eisner Advisory Group in Iselin, New Jersey.

The documentation needs to specify the exact number of minutes spent counseling the patient. A generalized statement of “more than three minutes up to 10 minutes” is insufficient for billing purposes. The documentation also needs to outline the details of the discussion, the strategies offered, and the patient’s response to the counseling efforts.

Know How Many Sessions to Report Per Year

“There is a Medicare limitation of eight sessions a year for the member, which can be verified through the CMS HIPAA Eligibility Transaction System (HETS),” Merrill says. For a beneficiary to receive another eight sessions of counseling during a second or subsequent year, at least 11 months need to have passed “since the first Medicare-covered counseling session was performed,” according to section 150.4 of chapter 18 of the Medicare Claims Processing Manual.

To calculate the next eligible date, you’ll begin counting months starting on the first month after your provider performed the first counseling session, and count until 11 full months have elapsed. So, if the provider performed the first of eight covered counseling sessions in March 2022, then the count started at the beginning of April 2022, which would have allowed the beneficiary to be eligible for a second round of counseling in March 2023.

Note: Private payer guidelines will differ, so be sure to check each payer’s policies.

Report Modifier 93 for Over-the-Phone Sessions

Some patients, due to location or physical limitations, are unable to travel to the practice. PCPs are permitted to provide smoking cessation counseling to patients over via telehealth, either using real-time audio-visual equipment or over the phone (i.e., audio-only). To indicate the provider performed cessation counseling over the phone, append modifier 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) to the appropriate smoking cessation counseling code.

The audio-only telemedicine modifier was added to the CPT^® code set Jan. 1, 2022, and the CPT^®Editorial Panel approved adding Appendix T: CPT^®codes that may be used for synchronous real-time interactive audio-only telemedicine service to the CPT^®book at the February 2022 meeting. Cessation codes 99406 and 99407 are on the list of approved codes in Appendix T, which also provides specific guidelines for using modifier 93.

Just as with in-person sessions, depending on how much time was spent providing smoking cessation counseling over a telephone call, you’ll assign 99406-93 or 99407-93 to report the service.