Primary Care Coding Alert

Question: We have a patient who wishes to quit smoking, even though he currently has no adverse health conditions associated with the habit. Can we still bill for a nicotine screening test, such as the Fagerstrom nicotine dependency screening, and counseling? If so, what is the best way to do this?

Codify Subscriber

Answer: Medicare coverage for smoking cessation efforts extends to any user of tobacco products, regardless of whether users are symptomatic (i.e. they have been diagnosed with a disease, or have experienced adverse health effects linked to tobacco use, or their smoking has been adversely affecting the therapeutic levels of any medication they are taking) or asymptomatic.

So, provided the counselor is recognized by Medicare, or is a qualified physician, and provided the patient is competent and alert at the time of the counseling, you can go ahead and bill for the services. If this is not a Medicare patient, check with the patient’s primary insurance to see what it does or does not cover in this regard.

To bill for the screen and the counseling, you will use one of the following CPT^® codes, regardless of the payer in question:

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

As these are time-based codes, your provider must ensure that the amount of time spent counseling the patient is documented in the medical record. Additionally, you cannot use the codes as add-ons. Any session that lasts, say, more than 13 minutes cannot be billed as 99406 with 99407 but solely as 99407.

In addition to documenting the time, your physician should also document that he:

• Asked the patient about tobacco use in the past 12 months;
• Advised him to quit;
• Assessed his willingness to attempt to quit;
• Assisted him with ways and means to quit; and
• Arranged a follow-up after 4-6 weeks.

(See, for example, the recommendations provided by the US Preventive Services Task Force at https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1)

You would then link the CPT^® code with one of the many ICD-10 codes that show a history of tobacco use. As your patient is a smoker, you could use any of the following:

• F17.2- — Nicotine dependence
• F17.21- — Nicotine dependence, cigarettes
• Z87.891 — Personal history of nicotine dependence
• Z71.6 — Tobacco abuse counseling.

Medicare guidelines allow for two cessation attempts per year, and each attempt may include up to four sessions. So, your office can bill Medicare for a maximum of eight sessions in a year. Other payers may have other limits.

Finally, if the counseling occurred during another evaluation and management (E/M) session, you should 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 code to ensure that you are reimbursed for both services.