Primary Care Coding Alert

Document time accurately to avoid chances of underpayments.

When reporting tobacco cessation counseling, you need to know what codes to select for the sessions performed while being aware of coverage guidelines. You should also be aware whether or not you can report a same day additional E/M encounter.

Use these four pointers to help you understand how to enjoy reporting success for these counseling codes each and every time.

1. Base Code Selection on Symptoms and Time

When your FP performs smoking cessation counseling, you will have to first check on whether the patient is having any symptoms of tobacco related problems. If the patient has tobacco associated signs and symptoms, you will have to report one of two CPT^® codes based on the amount of time your FP spent for the counseling:

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes)
• 99407 (…intensive, greater than 10 minutes)

Reminder: When your FP counsels an individual with signs and symptoms of tobacco related disease, you will have to report one of the above mentioned codes based on time spent in counseling. “Report only one code, either CPT^® 99406 or 99407,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, PA. “A parenthetic following code 99407 instructs that this code is not reported in conjunction with code 99406,” says Cindy Hughes, CPC, CFPC, consulting editor of Cindy Hughes Consulting in El Dorado, KS. “The codes are listed in a hierarchal structure from which the appropriate code for the duration of service is selected. It would be inappropriate to report both codes.”

On the other hand, when your clinician performs a preventive counseling in a patient who uses or is exposed to tobacco smoke but does not have any signs and symptoms of tobacco related disease, you should consider reporting the counseling session with one of the following two HCPCS codes, again based on the time spent:

• G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes)
• G0437 (... intensive, greater than 10 minutes).

Note: HCPCS codes G0436 or G0437 are appropriate to report for preventive counseling. These are again time based codes like 99406 and 99407. As both the sets of smoking cessation counseling codes are time based codes, your clinician will need to document time accurately so that you do not make the mistake of reporting an “intermediate” code when you actually could have reported an “intensive” counseling session. If time taken for the counseling is less than three minutes, then you cannot report it with either 99406 or G0436. It will instead become part of the E/M that you report for the visit and cannot be reported separately.

2. Know the Indications for Coverage

According to section 210.4.1 of the Medicare National Coverage Determinations Manual and section 150 of chapter 18 of the Medicare Claims Processing Manual maintained by the Centers for Medicare & Medicaid Services (CMS), Medicare will provide coverage for smoking and tobacco cessation counseling for patients (outpatient and hospitalized):

• Who use tobacco regardless of whether they exhibit signs or symptoms of tobacco related disease,
• Who are competent and alert at the time of counseling, and
• Who get counseling by a qualified physician or other Medicare-recognized practitioner.

According to the guidelines, CMS will provide coverage for two tobacco cessation counseling attempts in a year. In one attempt, your clinician can perform a maximum of four intermediate or intensive counseling sessions. So, in the period of one year, your clinician will only be able to perform a total of eight individual intermediate or intensive counseling sessions. Your clinician can perform another eight sessions of counseling for the patient in the second year only after 11 months have passed by since your clinician performed the first counseling session for the patient.

Waiver: According to Section 4104 of the Affordable Care Act, Medicare coinsurance and Part B deductible is waived for preventive tobacco cessation counseling codes G0436 and G0437. However, this waiver doesn’t apply for the symptomatic tobacco cessation counseling codes, 99406 and 99407.

3. Support Medical Necessity with Appropriate Diagnosis Codes

When reporting either of the codes for tobacco cessation counseling, you will need to support medical necessity of providing the counseling service by reporting appropriate diagnosis codes. Per Medicare, some of the diagnosis codes that you can report with G0436 and G0437 counseling codes include:

• F17.200 (Nicotine dependence, unspecified, uncomplicated)
• F17.201 (Nicotine dependence, unspecified, in remission)
• F17.210 (Nicotine dependence, cigarettes, uncomplicated)
• F17.211 (Nicotine dependence, cigarettes, in remission)
• F17.220 (Nicotine dependence, chewing tobacco, uncomplicated)
• F17.221 (Nicotine dependence, chewing tobacco, in remission)
• F17.290 (Nicotine dependence, other tobacco product, uncomplicated)
• F17.291 (Nicotine dependence, other tobacco product, in remission)
• Z87.891 (Personal history of nicotine dependence).

Other diagnosis codes that may be used, depending on the payer and the circumstances include:

• Z71.6 (Tobacco abuse counseling)
• Z72.0 (Tobacco use NOS)
• O99.33-(Smoking [tobacco] complicating pregnancy, childbirth, and the puerperium…)
• T65.2--(Toxic effect of tobacco and nicotine…).

“If the patient is symptomatic, such that you are using 99406 or 99407, you should consider reporting a diagnosis code that reflects the condition the patient has that is adversely affected by the use of tobacco in addition to one of the codes above,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “So, if the patient’s hypertension is adversely affected by his smoking, you would report I10 (Essential [primary] hypertension) in addition to a code that identifies his smoking when reporting 99406 or 99407.”

4. Know if You Can Report Additional E/M Code

Your clinician could perform the tobacco cessation counseling on the same day on which another E/M service was provided. “The tobacco cessation counseling should be in addition to the services provided during the E/M service,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa. “The notes should clearly illustrate the cessation counseling as well as the E/M. If the note is comprised of only cessation information, only those codes should be used. Time must be mentioned regardless of which cessation code is used.”

“When providing these services on the same date as a significant, separately identifiable evaluation and management (E/M) service, 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 E/M service to signify that it was distinct from the counseling,” Falbo says. “Third party payers should be queried to ensure they follow CMS and AMA rules concerning modifier 25.” “Depending on the payer will depend on whether or not the 25 modifier is required on the E/M service,” Hauptman adds.

Resources: For more information on tobacco cessation counseling codes, refer to the Medicare Claims Processing Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf.