Primary Care Coding Alert

Primary care providers spend a lot of time and energy working with patients on smoking cessation efforts, and you spend a lot of time billing 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or, if your provider spent greater than 10 minutes counseling the patient, 99407 (… intensive, greater than 10 minutes).

Even so, there are always a lot of questions surrounding the codes. Here are some answers to these questions to help you navigate Medicare (and some private payer) rules quickly and easily.

Who can receive the counseling?

Under Medicare’s National Coverage Determination (NCD) 210.4.1, any patient who uses tobacco, “regardless of whether they have signs or symptoms of tobacco-related disease,” and “who is competent and alert at the time that counseling is provided,” may receive the services (Source: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=342).

Who can provide the counseling?

“A qualified doctor or other Medicare-recognized provider must provide these visits” (Source: www.medicare.gov/coverage/counseling-to-prevent-tobacco-use-tobacco-caused-disease). In a typical primary care setting, that could include physician assistants, nurse practitioners, and clinical nurse specialists. Additionally, the services can be performed under Medicare incident-to guidelines, meaning that the patient must be established to your practice, a treating physician must have already seen the patient for the condition and provided a plan of care, and the billing physician must be available immediately within the office suite while the nonphysician practitioner (NPP) is providing the service.

How much counseling can a patient receive?

Providing the above criteria are met, “Medicare covers two cessation attempts spanning up to eight sessions per year. Each session is separately reportable with either 99406 or 99407,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

What is the cost of these services to the patient?

The Affordable Care Act (ACA) waived the copay for smoking cessation counseling beginning Jan. 1, 2011, and for Medicare patients, 99406 or 99407 have no deductible (Source: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=342).

However, “one of the disadvantages of 99406/99407 is that these codes may or may not be covered by private insurance carriers,” according to Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Thankfully, private payer policies are falling in line with Medicare coverage. For example, while Horizon Blue Cross Blue Shield of New Jersey will currently “deny 99406 or 99407 … when billed without an approved diagnosis of nicotine dependence, toxic effect of tobacco and nicotine, or personal history of tobacco use” (Source: www.horizonblue.com/providers/policies-procedures/policies/reimbursement-policies-guidelines/smoking-cessation), Blue Cross Blue Shield of Texas will provide “coverage … at no member cost-share for members with a nongrandfathered health plan” (Source: www.bcbstx.com/provider/pdf/cpcp006_preventive_services_policy.pdf).

What ICD-10 codes do I need to justify the service(s)?

CMS has provided a full list of appropriate diagnosis codes for use with 99406-99407 on their Medicare Learning Network Counseling to Prevent Tobacco Use website at www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#TOBACCO.

Unsurprisingly, many of the codes belong to the F17.- (Nicotine dependence) group, though you may also need to use a code from the T65.2- (Toxic effect of tobacco and nicotine) group. “These toxic effect codes are combination codes that describe the substance that was taken as well as the associated intent — accidental, intentional self-harm, assault, or undetermined,” explains Moore.

You would use these codes in situations where “someone with nicotine dependence [F17.-] is suffering a toxic effect, such as shortness of breath, as a consequence. So, you might code something like T65.222- [Toxic effect of tobacco cigarettes, intentional self-harm] in addition to F17.- to show that the smoker is both nicotine dependent and suffering the toxic effects of smoking intentionally,” Moore elaborates.

You might also use a T65.2- code on its own in situations where someone was not nicotine dependent but still suffering toxic effects of using tobacco and nicotine. So, “someone who occasionally uses chewing tobacco, but not enough or frequently enough to be considered dependent, and is suffering from, say, oral cancer, could be documented with T65.212- [Toxic effect of chewing tobacco, intentional self-harm] on its own, assuming the chewing tobacco was used intentionally,” Moore further explains.

Coding alert: Make sure you use the correct encounter code to go along with the appropriate diagnosis code. CMS recognizes use of Z87.891 (Personal history of nicotine dependence) as a covered ICD-10-CM code for 99406 and 99407 but not Z72.0 (Tobacco use). That’s because “Z72.0 only indicates the person uses tobacco and is not clinically dependent. If the person was dependent, of course, you would report an F17.- code, which is why it is an Excludes1 to Z72.0 and vice versa,” Moore cautions.

How do I document counseling time for 99406/99407?

The codes are counseling codes, so they are also time based. As the time parameters for 99406 are greater than three minutes up to 10 minutes, “once the time involved exceeds 10 minutes, you report one unit of 99407 regardless of the total length. So, whether it’s 11 minutes or 21 minutes, you just report 99407 once,” Moore explains.

And, whichever code you use, “the amount of time has to be documented in the note as well as a brief synopsis of what was discussed and the plan” Holle notes.