Pulmonology Coding Alert

Question: We reported 99407 with 99213 and the claim was denied, even though we used modifier 25 with 99213. We noticed that there are no Correct Coding Initiative (CCI) edits barring us from billing these together, so we can't figure out what the problem is. Can you advise?

Codify Subscriber

Answer: The code 99407 describes "Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes." This code may be reported in addition to other E/M services provided on the same day, but it does require face-to-face counseling by the physician personally to do so. Therefore, to report this service, the pulmonologist must personally be the one providing the direct counseling rather than having it done by another provider, such as a nurse or social worker. The two services should be distinct, but can be related to the same presenting problem. Documentation must support the time and details surrounding the counseling.

You are correct in noting that there are no CCI edits between 99407 and E/M codes, but Medicare and other payers prefer to use a modifier when reporting both these codes together. More specifically, 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)  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.

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. Once a person receives a total of eight sessions in the period of one year (365 days), another round of counseling can be taken up only after 11 months have passed since the first cessation counseling session was performed.

For example, a beneficiary received the first of eight covered sessions in January 2018. The count starts beginning February 2018. The beneficiary is eligible to receive a second series of eight sessions in January 2019. 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, diagnosis codes should 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.