99406 – Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes – Avreage fee amount- $12 – $18
99407 – Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes -Avreage fee amount- $25 – $30
Update from Medicare
Note: HCPCS code G0436 and G0437 will be discontinued effective 10/1/2016. CPT codes
99406 and 99407 are the remaining codes for tobacco cessation counseling. The beneficiary
copayment is waived for CPT codes 99406 and 99407.
Policy: Effective for claims with dates of service on and after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:
1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
2. Who are competent and alert at the time that counseling is provided; and
3. Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.
These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations. The diagnosis codes that should be reported for these individuals are ICD-9 codes 305.1, nondependent tobacco use disorder, or V15.82, history of tobacco use.
Counseling to Prevent Tobacco Use
Effective September 30, 2016, HCPCS codes G0436 and G0437 are deleted. Use existing CPT codes 99406 and 99407 for smoking and tobacco-use cessation counseling visits.
HCPCS/CPT Codes
99406 – Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 – Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes
ICD-10 Codes
F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A, and Z87.891
NOTE: Additional ICD-10 codes may apply
Who Is Covered
Outpatient and hospitalized Medicare beneficiaries for whom all of the following are true:
* Use tobacco, regardless of whether they exhibit signs or symptoms of tobacco-related disease
* Competent and alert at the time of counseling
* Counseling furnished by a qualified physician or other Medicare-recognized practitioner
Frequency
Two cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total
annual benefit covering up to 8 sessions per year Medicare Beneficiary Pays 99406 and 99407:
* Copayment/coinsurance waived
* Deductible waived
Tobacco Cessation Counseling – G0436/G0437 and 99406/99407
Medicare Part B already covers cessation counseling for individuals who:
1. Use tobacco and have been diagnosed with a recognized tobacco-related disease
2. Use tobacco and exhibit symptoms consistent with a tobacco-related disease
In November 2009, based upon authority to cover ‘additional preventive services’ for Medicare beneficiaries if certain statutory requirements are met, the CMS initiated a new national coverage analysis. This analysis was to evaluate whether the existing evidence on counseling to prevent tobacco use is sufficient to extend national coverage for cessation counseling to those individuals who use tobacco (but do not have signs or symptoms of tobacco-related disease).
One of these statutory requirements is that the service be categorized as a grade A (strongly recommends) or grade B (recommends) rating by the US Preventive Services Task Force (USPSTF).
CR 7133 instructs that, effective for claims with dates of service on and after August 25, 2010, CMS will cover counseling to prevent tobacco use for outpatient and hospitalized Medicare beneficiaries:
1. Who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease)
2. Who are competent and alert at the time that counseling is provided
3. Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner
These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations.
The diagnosis codes that should be reported for these individuals are:
- ICD-9 code 305.1 (non-dependent tobacco use disorder)
- ICD-9 code V15.82 (history of tobacco use)
The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use for dates of service on or after January 1, 2011. These are in addition to the two CPT Codes 99406 and 99407 that currently are used for tobacco cessation counseling for symptomatic iindividuals. Medicare will waive the deductible and coinsurance/copayment for counseling and billing with these two new G codes on or after January 1, 2011.
The new G codes for use on claims with dates of service on or after January 1, 2011 are:
- G0436: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than three minutes, up to 10 minutes; Short Descriptor: Tobacco-use counsel three to 10 minutes
- G0437: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes; Short Descriptor: Tobacco-use counsel >10 minutes.
Note also the following claims processing information from CR 7133:
• Claims submitted with the tobacco cessation counseling codes of G0436 and G0437, but which lack a required diagnosis code (305.1 or V15.82) will be denied with Claim Adjustment reason Code (CARC) 167 (This (these) diagnosis (es) is (are) not covered. Note: Refer to the 835 Health Care Policy Identification Segment (loop 2110 Service Payment Information REF), if present.), Remittance Advice Remarks Code (RARC) M64 (Missing/incomplete/invalid other diagnosis), and Group Code PR assigning financial liability to the beneficiary if a claim is received with a signed Advance Beneficiary Notice (ABN). If no ABN is on file, Group Code CO is used to assign financial liability to the provider.
• Claims are accepted for G0436 and G0437 with revenue code 0942 on TOB 12X, 13X, 22X, 23X, 34X, and 85X.
• Claims are accepted for G0436 and G0437 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II under the MPFS.
• Claims are accepted for G0436 and G0437 with revenue code 052X when billed on TOBs 71X or 77X.
• Claims are accepted for G0436 and G0437 with revenue code 0510 when billed by IHS facilities.
• Institutional claims billed on TOBs other than 12X, 13X, 22X, 23X, 34X, 71X, 77X, or 85X will be returned to the provider. maximum for this time period or occurrence has been reached.), RARC N362 (The number of days or units of service exceeds our acceptable maximum.), and Group code PR if a signed ABN is on file. A Group Code of CO is assigned if no ABN is on file.
NOTE: In calculating a 12-month period, 11 months must pass following the month in which the 1st Medicare covered cessation counseling session was performed.
• Medicare will allow payment for a medically necessary Evaluation and Management (E/M) service on the same date as tobacco cessation counseling, provided it is clinically appropriate. Such E/M service should be reported with modifier 25 to indicate it is separately identifiable from the tobacco use service.
Coverage Limitation
Contractors shall allow payment for a medically necessary E/M service on the same day as the smoking and tobacco-use cessation counseling service when it is clinically appropriate. Physicians and qualified non-physician practitioners shall use an appropriate HCPCS code, such as HCPCS 99201– 99215, to report an E/M service with modifier 25 to indicate that the E/M service is a separately identifiable service from G0375 or G0376.
Contractors shall only pay for 8 Smoking and Tobacco-Use Cessation Counseling sessions in a 12-month period. The beneficiary may receive another 8 sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered cessation session was performed. 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 cessation session was performed and count until 11 full months have elapsed.
Claims for smoking and tobacco use cessation counseling services shall be submitted with an appropriate diagnosis code. 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.
NOTE: This decision does not modify existing coverage for minimal cessation counseling (defined as 3 minutes or less in duration) which is already considered to be covered as part of each Evaluation and Management (E/M) visit and is not separately billable.
Reimbursement Guidelines
Optum will align reimbursement with Medicare including 2 cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with a total of up to 8 face-to-face sessions during a 12-month period for individuals who use tobacco – regardless of whether there are signs or symptoms of tobacco-related disease. These sessions must be provided by a qualified health care provider.
CPT codes for tobacco cessation counseling for symptomatic individuals are:
• 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
• 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
HCPCS codes for tobacco cessation counseling for asymptomatic individuals are:
• G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than three minutes, up to 10 minutes
• G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes Minimal counseling (<3 -25="" a="" and="" appended="" applicable="" as="" be="" cessation="" code="" counseling="" cpt="" date.="" distinct="" e="" either="" hcpcs="" is="" minutes="" modifier="" not="" on="" or="" p="" reimbursable="" reporting="" same="" separate="" service.="" service="" should="" the="" to="" tobacco="" when="">
Coding Information
There two CPT Codes 99406 and 99407 that are used for tobacco cessation counseling for symptomatic individuals.
• 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
• 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
The CMS has created two G codes for billing for tobacco cessation counseling services to prevent tobacco use for asymptomatic patients. These are in addition to the two CPT Codes 99406 and 99407 that currently are used for tobacco cessation counseling for symptomatic individuals.
• G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than three minutes, up to 10 minutes
• G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes The ICD-10 codes diagnosis codes that should be reported for individuals who do not have signs or symptoms of tobacco-related disease individuals are: [MLN, 2015]
• F17.200: Nicotine dependence, unspecified, uncomplicated
• F17.201: Nicotine dependence, unspecified, in remission
• F17.210: Nicotine dependence, cigarettes, uncomplicated
• F17.211: Nicotine dependence, cigarettes, in remission
• F17.220: Nicotine dependence, chewing tobacco, uncomplicated
• F17.221: Nicotine dependence, chewing tobacco, in remission
• F17.290: Nicotine dependence, chewing tobacco, uncomplicated
• F17.291: Nicotine dependence, unspecified, in remission
• Z87.891: Personal history of nicotine dependence
Minimal counseling
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Medicare also allows for the reporting an E/M visit (99201-99215) in addition to the tobacco-counseling, if modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M [Phurrough].
Post-Payment Review for Smoking and Tobacco-Use Cessation Counseling Services
As with any claim, Medicare may decide to conduct post-payment reviews to determine that the services provided are consistent with coverage instructions. 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 post-payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.
Common Working File (CWF) Inquiry
The Common Working File (CWF) maintains the number of smoking and tobacco-use cessation counseling sessions rendered to a beneficiary. By entering the beneficiary’s health insurance claim number (HICN), providers have the capability to view the number of sessions a beneficiary has received for this service via inquiry through CWF.
Provider Access to Smoking and Tobacco-Use Cessation Counseling Services Eligibility Data
Providers may access coverage period remaining smoking and tobacco-use cessation counseling sessions and a next eligible date, when there are no remaining sessions, through the 270/271 eligibility inquiry and response transaction.
Medicaid Guidelines – SMOKING CESSATION COUNSELING:
In support of the U.S. Department of Health and Human Service’s Clinical Practice Guideline 2008 Update “Treating Tobacco Use and Dependence,” Medicaid began covering smoking cessation counseling to pregnant women, effective January 1, 2009, in practitioner’s offices and in hospital OPDs. This counseling complements Medicaid covered benefits for smoking cessation coverage, which include prescription and non-prescription smoking cessation products. These codes group to APG 451. Effective January 1, 2010, Medicaid will cover smoking cessation counseling during a medical visit to pregnant and postpartum women and children and adolescents ages 10 to 21.
Reimbursement for smoking cessation counseling (SCC) must meet the following criteria:
• Services must be provided face-to-face.
• ONLY available for Medicaid-eligible pregnant females, women up to 6 months postpartum, and children and adolescents ages 10-21 who smoke. The claim must have a diagnosis of pregnancy (ICD-9- CM Diagnosis Codes: 630-677, V22, V23, V28).
• Practitioners and clinics must use the appropriate ICD-9 diagnosis code:
o 305.1 – Tobacco use disorder. (Use for children and adolescents ages 10 up to 21).
o 649.03 – Tobacco use disorder complicating pregnancy, childbirth or the puerperium – antepartum. (Use for pregnant women who smoke).
o 649.04 – Tobacco use disorder complicating pregnancy childbirth or the puerperium – postpartum. (Use for post-partum women who smoke).
• Smoking cessation counseling must be provided by a physician, registered physician’s assistant, registered nurse practitioner, or licensed midwife during a medical visit (no group sessions), and is only payable when accompanied by an the appropriate E&M code (99201-99205, 99211-99215) and/or the appropriate preventive medicine code (99383-99386, 99393-99396). EXCEPTION- an E&M code is NOT necessary for practitioners billing for Global Obstetrical Care, which is billed at the end of pregnancy.
• Currently physicians, nurse practitioners, and licensed midwives and (whose fees are not included in the facility rate or APG); Article 28 hospital outpatient departments will be allowed to bill for SCC;
• Upon approval of the APG payment method by CMS, D&TCs and FQHCs that bill using APGs will be allowed to bill for SCC.
• Pregnant women will be allowed up to 6 counseling sessions within a continuous 12-month period during their pregnancy.
• Postpartum women will be allowed 6 counseling sessions during the 6 month postpartum period.
• Children and adolescents ages 10-21 will be allowed up to 6 counseling sessions in a continuous 12- month period.
• Providers should bill for these services using the following CPT procedure codes:
99406 – Smoking cessation counseling, 3 to 10 minutes
99407 – Smoking cessation counseling, greater than 10 minutes Only one procedure code per day may be billed.
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