Pulmonology Coding Alert

Question: Our physician assistant (PA) performed smoking cessation counseling with a patient who presented with bronchitis. The patient didn’t have signs of emphysema or COPD, but we performed the counseling as a way to share the advantages of quitting smoking. The PA said we can’t report 99406 for this since the patient doesn’t have any conditions that are related to smoking, but the pulmonologist said we can. Who is right?

West Virginia Subscriber

Answer: The pulmonologist is right. 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 PA 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.

If your PA 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 they instead furnish 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 “>three minutes”), as the latter does not represent the patient-specific session.

Medicare covers two individual smoking cessation counseling attempts per year. Each period 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.”