Primary Care Coding Alert

Question: CMS deleted HCPCS codes G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) and G0437 (… intensive, greater than 10 minutes). What is the best way to code smoking prevention efforts for an asymptomatic smoker?

Vermont Subscriber

Answer: Effective October 1, 2016, CMA deleted HCPCS codes G0436 and G0437. In their place, CMS authorized the use of 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 section on Counseling Risk Factor Reduction and Behavior Change Intervention in the CPT^® manual states that behavior change services such as these are for “persons without a specific illness.” This is reinforced in the CMS guidelines (https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf), which state that these codes are to be used “for outpatient and hospitalized Medicare beneficiaries [who] use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease.”

Consequently, you can code both symptomatic and asymptomatic patients this way. The only caveat is whether the patient does show signs of an abnormality. In that case, if the physician does the additional work to address the abnormality, you should use a problem-oriented evaluation and management (E/M) service code from the 99201-99215 set. And don’t forget to add 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 code to show that the E/M service was significant and separately identifiable from the cessation counseling.

As a side note, CMS guidelines allow two cessation attempts per calendar year for both 99406 and 99407, with a maximum of four sessions per attempt for a total of eight sessions in a calendar year.