Pulmonology Coding Alert

Question: Do I still need a plan and referral to support smoking cessation counseling? What, if any, are the limits on how often we can bill for this service?

North Carolina Subscriber

Answer: CMS does not include an action plan and referral as part of its national requirements for reporting smoking counseling cessation.

While such may be the clinical goal for patient care, the physician must discuss all available options only for the patient to select. The service may simply end after the discussion if the patient shows no interest in initiating a mutually agreed upon plan.

The Medicare National Coverage Determinations Manual (Section 210.4) and Medicare Claims Processing Manual (Chapter 32, Section 12.6, "Post-Payment Review for Smoking and Tobacco-Use Cessation Counseling Services") do not require that covered counseling must include a plan for the patient to quit, and a referral to a treatment center.

Take note: Section 12.6 of Chapter 32 of the Medicare Claims Processing Manual states that "Providers must keep patient record information on file for each Medicare patient for whom a Smoking and Tobacco-Use Cessation Counseling claim is made.

These medical records can be used in any postpayment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed."

Nationally, Medicare has a frequency limitation for both 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (... intensive, greater than 10 minutes).

Ensure the patient has not exceeded these benefits:

• Year 1: Two attempts in a 12-month period, where each attempt may include a maximum of four counseling sessions.A qualified physician or other Medicare recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. So a beneficiary may receive eight smoking and tobacco-use cessation counseling sessions in a 12-month period.

• Year 2: Another eight counseling sessions during a second or subsequent year after 11 full months have passed since the first Medicarecovered cessation counseling session was performed.

Example: If the first of eight covered sessions was performed in August 2008, a second series of eight sessions may begin in August 2009. 

-- The answers to the Reader Questions and You Be the Coder were provided and reviewed by Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta; and Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.