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Pulmonology Coding Alert

Look at Diagnosis, Payer to Code Kick-the-Habit Session

Published on Mon Sep 24, 2007

CPT to include smoking-cessation codes in 2008

Because no global rules exist for reporting smoking-cessation sessions, you've got to be on the prowl for payer-specific coding preferences -- or you risk an insurer denial for the service.

"Some private payers do not utilize the HCPCS codes, and prefer using standard CPT codes (or vice versa)," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Also, "Medicare rules don't always carry over to the private payers, and if they do, it's usually not right away," she says.

To garner payment for smoking-cessation counseling, zoom in on the diagnosis and insurer. Here are some options.


Use Special Services Code for Some Payers

For private payers that don't accept HCPCS level II codes, you may use a special services code or possibly a risk-factor reduction code. Choose between these code sets based on diagnosis.

Well: When a patient doesn't have a smoking-related illness or disease that made him a candidate for the program, consider 99401-99412 (Counseling and/or risk factor reduction intervention[s] ...). Warning: These codes are not for patients with symptoms or established illness, according to CPT's introductory notes for this section.

Sick: If the patient has a smoking-related illness, disease or symptom, consider using 99078 (Physician educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions]). However, remember that 99078 comes with these pitfalls:

  • many insurance companies don't cover this code
  • the code is specific to physician education in a group setting
  • the general code doesn't allow for time variations.


Count Annual Counseling Attempts

If you report smoking cessation for a Medicare beneficiary, you can capture various lengths for a patient who has an established illness, disease or symptom. For smoking-cessation counseling provided to an individual, Medicare now accepts two HCPCS level II G codes:

  • G0375 -- Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
  • G0376 -- ... intensive, greater than 10 minutes.

Medicare allows two counseling attempts every 12 months. Each attempt includes up to four intermediate or intensive sessions, for a total of eight possible G0375-G0376 visits in a year, Pohlig says.

However, she also explains that "Medicare will cover this service only if the patient has documented tobacco dependence (305.1, Tobacco use disorder) and either has a co-morbidity that smoking complicates or uses a prescription drug that may lead to an adverse reaction or negative outcome as a result of continued smoking."


CPT Code Coming in 2008

CPT will add both of these G codes Jan. 1, 2008, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. CPT has not decided on the number of yearly visits it will allow for these new codes, Plummer says.

Many private insurers will not accept the G codes. Before filing a smoking cessation claim with G0375 or G0376 to a non-Medicare entity, call the insurer and see if it accepts the G codes -- or possibly S9075 (Smoking cessation treatment). If the insurer does not recognize the HCPCS codes, consider including the cessation counseling as a part of the overall E/M time, such as 99201-99215 (Office or other outpatient visit ... ).

Remember: When the pulmonologist spends more than half of the encounter's total face-to-face time on counseling and/or coordination of care, he can use time as the controlling factor in selecting the E/M service level.

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