Pulmonology Coding Alert

Does counseling need to be face-to-face? Find out.

If you notice the phrase, “smoking cessation counseling” in your provider’s documentation and are confused about the codes available, you’re not alone. But don’t worry. Pulmonology Coding Alert is here to help.

Use the answers to the five frequently asked questions below to help you overcome coding challenges and understand the specific Centers for Medicare & Medicaid Services (CMS) rules regarding smoking cessation reimbursement.

Know Who Qualifies for Cessation Counseling

Question: Which Medicare beneficiaries qualify for tobacco cessation counseling?

Answer: CMS’ National Coverage Determination (NCD) on Counseling to Prevent Tobacco Use (>www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=342&ncdver=2&bc=AgAAQAAAAAAA&) maintains specific guidelines for 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (… intensive, greater than 10 minutes).

“Medicare Part B will cover tobacco cessation counseling for outpatient and hospitalized patients who use tobacco, even if they are not showing signs or symptoms of tobacco-related diseases,” says Denae Merrill, CPC, CDEO, CRC, RADV (risk adjustment data validation) project and training manager in Michigan.

Additional requirements for your provider to receive reimbursement for tobacco cessation counseling include:

• Patient is competent and alert at the time of the encounter
• A qualified physician or other Medicare-recognized practitioner provides counseling

Recognize the Time Differences Between 99406 and 99407

Question: A patient visits your practice, and the pulmonologist provides smoking cessation counseling to ensure the patient knows the risks of continued smoking and to encourage them to quit. The patient is not showing signs of a smoking-related disease, such as COPD or emphysema. Which smoking cessation code should you report for the encounter?

Answer: Time is the main difference between the two smoking cessation counseling codes. When the pulmonologist provides the cessation counseling, you’ll assign 99406 or 99407 depending on the time spent providing the counseling to the patient. Plus, you may report these codes in conjunction with any evaluation and management (E/M) service that may be furnished on the same day to address other issues. However, only a physician or other qualified healthcare professional recognized by Medicare can bill the agency directly for the service.

When you examine the descriptor for 99406, you’ll see the minimum time threshold for counseling is three minutes. During the E/M visit, if the physician provides counseling that occupies fewer than three minutes, then the counseling is covered within the E/M service, and you shouldn’t report it separately. If the physician provides smoking cessation counseling for more than three minutes, up to 10 minutes, on the same day as the scheduled E/M visit to assess the patient’s underlying condition, then you’ll 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 appropriate E/M code to show the E/M service is a separately identifiable service from the cessation counseling, which you’ll report using 99406. But if the physician spends more than 10 minutes counseling the patient about tobacco cessation on the same date as the E/M visit, you’ll append modifier 25 to the E/M code and assign 99407.

“As with all time-based CPT^® codes, ensure the documentation includes the time spent providing face-to-face counseling to the patient. Even though the CPT^® code descriptors allow for a range of time, it is advised to document the specific time spent in face-to-face counseling,” says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, AAPC Fellow, senior manager of healthcare services of Eisner Advisory Group in Iselin, New Jersey.

Important: The documentation needs to specify the exact number of minutes spent counseling the patient. A generalized statement of “more than three minutes up to 10 minutes” is insufficient for billing purposes. The documentation also needs to outline the details of the discussion, the strategies offered, and the patient’s response to the counseling efforts.

Make Sure to Report a Diagnosis Code

Question: Smoking and tobacco use cessation counseling services require an appropriate diagnosis code, but what if the patient isn’t presenting symptoms of tobacco-related diseases? What diagnosis code do you report?

Answer: The diagnosis code you need to report relates to the patient’s tobacco use. According to Section 12.1 of the Medicare Claims Processing Manual, “Claims for counseling to prevent tobacco use services shall be submitted with an appropriate diagnosis code” (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf).

You’ll find appropriate diagnosis codes in the ICD-10-CM code set under:

• F17.2- (Nicotine dependence)
• Z87.891 (Personal history of nicotine dependence)
• T65.2- (Toxic effect of tobacco and nicotine)

“Diagnoses should reflect either patient’s dependence on nicotine (F17.2-) or personal history of nicotine dependence (Z87.891), as well as any identified toxic effects of tobacco (T65.2-) identified,” Clark says.

Since different payers may have different diagnosis requirements, make sure to check your individual payer preferences to ensure you’re assigning the correct diagnosis codes on your claim.

Additional characters required: Pay attention to the coding instructions for F17.2- and T65.2-, as additional characters are required to complete the specific code for your diagnosis. Code subcategory F17.2- requires 5th and 6th characters to complete a code, whereas T65.2- requires 5th, 6th, and 7th characters to complete a code.

Familiarize Yourself With Frequency Guidelines

Question: How many smoking and tobacco use cessation counseling sessions can a provider furnish to a patient in one year?

Answer: “There is a limitation of eight sessions a year for the member, which can be verified through the CMS HIPAA Eligibility Transaction System (HETS),” Merrill says. For a beneficiary to receive another eight sessions of counseling during a second or subsequent year, at least 11 months need to have passed “since the first Medicare-covered counseling session was performed,” according to the Medicare Claims Processing Manual. 

To calculate the next eligible date, you’ll begin counting months starting on the first month after the first counseling session was performed, and count until 11 full months have elapsed.

This means that if the provider performed the first of eight covered counseling sessions in March 2022, then the count starts at the beginning of April 2022, which allows the beneficiary to be eligible for a second round of counseling in March 2023.

Does CMS Cover Telemedicine Counseling?

Question: Can smoking and tobacco use cessation counseling occur over a telemedicine visit?

Answer: In the CPT^® code set, 99406 and 99407 feature star icons next to the codes, which indicate the American Medical Association (AMA) supports reporting the codes as telehealth services. With the COVID-19 public health emergency (PHE), providers have used telehealth services to ensure patients receive routine care — or in this case, reliable counseling for smoking and tobacco cessation.

Payers may have their own rules about which codes are reportable for telehealth services, so you should confirm payer policy. For instance, “as an added benefit, CPT^® codes 99406 and 99407 are listed as Medicare-allowed telehealth services and can be provided via audio-only interaction,” Clark says. This information is available in a file on CMS’ List of Telehealth Services webpage (www.cms.gov/Medicare/Medicare-general-information/telehealth/telehealth-codes). However, to ensure your practice receives reimbursement, the documentation needs to clearly show the provider furnished the counseling service via telehealth communications.