Pulmonology Coding Alert

Do not miss using the appropriate ICD-10 codes, document 5 A’s, and more.

Considering the importance of smoking cessation as a behavior modification intervention, Medicare provides guidelines on how providers can work their way to successful claims for the counseling sessions.

The focus of renewed interest in these codes lies in the fact that they “go hand in hand with the lung cancer screening codes,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

“If the patient is eligible for low dose computed tomography (LDCT) because they are current smokers, a comprehensive care model would suggest that you would not just screen the patient for lung cancer, you would also try to reduce their risk by counseling them to stop smoking.”

Here’s your lowdown of the basics – and top issues – that will keep you on the right track.

Start by Getting the Basics Right

Medicare coverage extends to one-on-one tobacco cessation counseling for Medicare beneficiaries:

• 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
• Who get counseling by a qualified physician or other Medicare-recognized practitioner.

Frequency: Two cessation attempts are allowed per year. Each attempt may include a maximum of four intermediate or intensive sessions, with the total annual benefit covering up to eight sessions per year.

In the real world, “There is no defined protocol unless the patient is enrolled in a formal program,” explains Pohlig. “Pulmonologists would see the patient as a normal part of their chronic disease management, which could be every few months or longer. The success is truly based on the patient’s willingness to quit.”

Payment: The copayment/coinsurance and deductible are waived. As per the current rules and regulations, only a physician or a qualified health care provider may directly bill for this service. A respiratory therapist can provide smoking cessation counseling “incident to” a physician’s service under Part B of Medicare.

Plus: Minimum counseling of less than three minutes is covered within an E&M visit, and not separately billable.

Know the Correct Codes to Use

Smoking cessation counseling codes are covered by Medicare, provided you meet all the guidelines.

For one-on-one face-to-face counseling with the qualified physician or other Medicare-recognized practitioner, you have two possibilities for patients who smoke and have associated signs and symptoms:

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

Added in 2016: Do not use 99407 in conjunction with 99406 on the same date. This is “to clarify that if it is greater than 10 minutes, only one code is used rather than using two codes to quantify the time: eg, 16 min is erroneously reported as 99407 (>10 min) with 99406 for the remaining time (> 3min),” tells Pohlig.

For asymptomatic patients who smoke, choose between the following HCPCS codes:

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

Note: These are time-based codes. Therefore, remind your providers to always mention the duration of the session in documentation so the correct code can be reported.

ICD-10 codes: To demonstrate a positive history of tobacco use, you may pick from one of the following ICD-10 codes for nicotine use:

• F17.2~ —Nicotine dependence
• F17.200 — Nicotine dependence, unspecified, uncomplicated
• F17.201 — Nicotine dependence, unspecified, in remission
• F17.203 — Nicotine dependence, unspecified, with withdrawal
• F17.208 — Nicotine dependence, unspecified, with other nicotine-induced disorders
• F17.209 — Nicotine dependence, with unspecified nicotine induced disorders
• F17.21~ — Nicotine dependence, cigarettes
• F17.22~ — Nicotine dependence, chewing tobacco
• F17.29~ — Nicotine dependence, other tobacco product
• Z87.891 — Personal history of nicotine dependence
• 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.

Do Not Expect Medicare to Pay for Group Counseling

For a group counseling session, you may also use HCPCS code S9453 (Smoking cessation classes, non-physician provider, per session). Don’t miss the guideline stating that these classes are not payable by CMS.

“Medicare only recognizes this service when performed by a recognized provider,” clarifies Pohlig, “although some commercial payers may contract with entities to provide group classes.”

What it includes: A non-physician provider, preferably one specially trained in techniques to help people stop smoking, leads class members in the sessions. Preferred smoking cessation programs include at least four sessions over at least a two week period to help ensure effective breaking of habits. The S code represent drugs, supplies and services, which do not yet have a permanent national code.

Document the 5A’s to Quitting

Proper documentation for a successful claim for smoking and tobacco-use cessation counseling must clearly demonstrate sufficient evidence from the patient history that:

• a) The patient uses tobacco, whether or not he shows any related signs or symptoms
• b) The patient is alert and competent to receive the counseling services.
• c) The counseling took place under a qualified health care provider.

Watch the A’s: In addition, you must also include the details of the counseling session. Your documentation must demonstrate that you:

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

For your EHR systems, you may follow http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/ehr-tobacco-cessation.pdf.

Counseling with E/M: In case you happen to provide this counseling service on the same day as another E/M service, such as 99213, you will need to 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 in order to be paid for both services.

The road ahead: “Smoking cessation counseling requires attention to detail when it comes to documentation,” cautions Pohlig. “Make sure the time and details of counseling are noted. It is also important to document the symptomatic patient’s condition to distinguish between and support the use of the available code choices.”