Pulmonology Coding Alert

Know when 99406 is the right choice — and when it’s not.

Many pulmonology patients are eager to quit smoking but have trouble sticking to a program, while others quit due to health issues. Pulmonologists tend to see both types of patients, and in most cases, they will implement smoking cessation programs to help patients give up the habit.

If the smoking cessation codes confuse you, you’re not alone. We’ve rounded up three of the most common questions submitted to Pulmonology Coding Alert on this topic and researched the answers so you can keep reporting these services appropriately.

Take Note of Time for 99406

Question: Your nurse practitioner (NP) performs smoking cessation counseling with a patient who is not yet showing signs of COPD or emphysema, just to ensure he knows the risks of continuing to smoke and to encourage him to quit. Our physician said we can’t report 99406 for this if the patient doesn’t have a smoking-related condition. Is this true?

Answer: No. CMS covers smoking and tobacco use cessation counseling for outpatient and hospitalized Medicare beneficiaries who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease.

When the NP performs the service, you may report codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (… intensive, greater than 10 minutes) for smoking cessation counseling under Medicare Part B in conjunction with any evaluation and management (E/M) service that may be provided on the same day to address other issues, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. Only the physician or other qualified healthcare professional recognized by Medicare can bill Medicare directly for the service.

If your practitioner provides minimal counseling, say three minutes or less, along with the E/M visit, it’s covered within the E/M service and not reported separately. If the NP furnishes the smoking cessation counseling services for more than three minutes on the same day as a scheduled office visit, you may 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 indicate that the E/M service is a separately identifiable service from smoking cessation counseling — for example, 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient …) plus 99406.

“Make sure that the documentation includes a specified number of minutes (such as, five minutes) rather than a generalized code descriptor (such as ‘>3 minutes up to 10 minutes’), as the latter does not represent the patient-specific session,” Pohlig says.

Medicare covers two individual smoking cessation counseling attempts per year. Each attempt may include a maximum of four intermediate OR intensive sessions, with the total benefit covering up to eight sessions in a 12-month period. “The beneficiary may receive another eight sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered counseling session was performed,” CMS says in Transmittal 3848. “To start the count for the second or subsequent 12-month period, begin with the month after the month in which the first Medicare covered counseling session was performed and count until 11 full months have elapsed.”

If CCI Doesn’t Bundle E/M, Counseling, Why Is Modifier 25 Necessary?

Question: You report 99407 with 99213 and the claim is denied. You look up the Correct Coding Initiative (CCI) edits, but there are no edits barring you from billing these together, so you can’t determine what might be wrong with your claim.

Answer: It’s true that 99407 may be reported in addition to other E/M services provided on the same day without any CCI edits blocking the pairing. However, Medicare and other payers instruct you to use a modifier when reporting both these codes together, Pohlig says. More specifically, modifier 25 should be used with 99213. Sometimes, the payer may hold the claim, and request to see the documentation in support of both services. If the documentation is not received, the claim will be denied. Then, an appeal is warranted.

Remember that 99407 does require face-to-face counseling by the practitioner, and documentation must support the time and details surrounding the counseling, so it’s possible that one of these issues was the problem when you reported the codes to the payer.

Another possibility is that the service does not meet the payer’s coverage criteria. For instance, many payers cover two attempts at smoking and any other tobacco-use cessation counseling, and in each attempt, only four counseling sessions are covered. So, in one year, a total of eight sessions will be covered by payers who follow this lead. Therefore, it’s possible that you exceeded the frequency guidelines.

For example, a beneficiary received the first of eight covered sessions in January 2019. The count starts beginning February 2019. The beneficiary is eligible to receive a second series of eight sessions in January 2020. Other payers may follow their own coverage guidelines. If your patient does not meet his payer’s coverage guidelines, that could explain the denial.

Finally, claims for smoking and tobacco use cessation counseling services require an appropriate diagnosis code. According to CMS, include the most appropriate diagnosis code representing the patient’s tobacco use. Additional diagnosis codes can also be used to reflect the condition the patient has that is adversely affected by tobacco use or the condition the patient is being treated for with a therapeutic agent whose metabolism or dosing is affected by tobacco use. As with coverage requirements, other payers may have different diagnosis requirements. Check to ensure that the diagnosis(es) you used on the claim are correct.

In the end, if your claim passes all of the criteria suggested above and is still not accepted and paid by the payer, then you need to call the payer for further explanation or otherwise accept the payer’s decision on the claim. A payer may only cover these services when reported by a provider specifically contracted to provide these services to its members.  

Question: Which Medicare patients qualify for tobacco cessation counseling?

Answer: Medicare maintains very specific guidelines for 99406 and 99407, according to the agency’s Fact Sheet on Counseling to Prevent Tobacco Use.

According to the CMS policy, you can collect for tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries as long as the following criteria are met:

• The patient uses tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
• The patient is competent and alert at the time of counseling
• The counseling is furnished by a qualified physician or other Medicare-recognized practitioner

Bonus: Medicare waives the copayment/coinsurance as well as the deductibles when you report 99406 or 99407.