Procedure code description
• 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
Tobacco Use Cessation Counseling
Medicare covers counseling for tobacco cessation for outpatients and for inpatients. Inpatients are covered only if counseling for tobacco use is not the primary reason for the patient’s hospital stay. Medicare covers 2 cessation attempts per year.
The counseling during an E/M service must be either intermediate or intensive. Intermediate counseling is 2 to 3 sessions of 3 to 10 minutes each. Intensive counseling is 4 sessions of more than 10 minutes each. Counseling involving only 1 session lasting less than 3 minutes is considered part of an E/M service and is not reimbursed separately. Each attempt may include a maximum of four intermediate or intensive counseling sessions. The total annual benefit is for 8 sessions in a 12 month period.
Services may be provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, qualified psychologist or clinical social worker. CMS does not currently have specific training requirements, but may in the future. The counseling must be provided face-to-face with the patient.
These services are reported using CPT-4 code 99406 (intermediate, E/M counseling service) or code 99407 (intensive, E/M counseling service). The diagnosis code 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.
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.
The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use. These are in addition to the two CPT codes 99406 and 99407 that currently are used for tobacco cessation counseling for symptomatic individuals. They will appear in the quarterly coding updates for January 2011 and the TOS code is 1.
• G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
• Short Descriptor: Tobacco-use counsel 3-10 min
• G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes
• Short Descriptor: Tobacco-use counsel >10 min
In addition, two new, temporary C codes have been created for facilities paid under the Outpatient Prospective payment System (OPPS) when billing for counseling to prevent tobacco use and tobacco-related disease services during the interim period of August 25, 2010, through December 31, 2010. They will appear in the quarterly coding updates for October 2010, and the TOS code is 1.
• C9801: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
• Short descriptor: Tobacco-use counsel 3-10 min
• C9802: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes
• Short descriptor: Tobacco-use counsel >10min During the same interim period of time between August 25, 2010, and December 31, 2010, carriers shall pay claims for these tobacco-cessation counseling sessions with unlisted code 99199.
The CMS will allow two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate OR intensive sessions, with a total benefit covering up to 8 sessions per year per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than 3 minutes but less than 10 minutes), or intensive (more than 10 minutes) cessation counseling sessions for each attempt.
7133-04.4.2 CWF shall deny counseling to prevent tobacco use services (HCPCS G0436, G0437, 99406, 99407) that exceed a combined total of 8 sessions within a 12-month period.
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.
Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Coding (Rev. 2058, Issued: 09-30-10, Effective: 08-25-10, Implementation: 01-03-11)
The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use for those individuals who use tobacco but do not have signs or symptoms of tobacco-related disease. These are in addition to the two CPT codes 99406 and 99407 that currently are used for smoking and tobacco-use cessation counseling for symptomatic individuals.
The following HCPCS codes should be reported when billing for counseling to prevent tobacco use effective January 1, 2011:
G0436 – Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes Short descriptor: Tobacco-use counsel 3-10 min G0437 – Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes Short descriptor: Tobacco-use counsel >10min
NOTE: The above G codes will not be active in contractors’ systems until January 1, 2011.
Therefore, contractors shall advise non-outpatient perspective payment system (OPPS) providers to use unlisted code 99199 to bill for counseling to prevent tobacco use and tobacco-related disease services during the interim period of August 25, 2010, through December 31, 2010. On January 3, 2011, contractor’s systems will accept the new G codes for services performed on or after August 25, 2010. Two new C codes have been created for facilities paid under OPPS when billing for counseling to prevent tobacco use and tobacco-related disease services during the interim period of August 25, 2010, through December 31, 2010:
C9801 – Smoking and tobacco cessation counseling visit for the asymptomatic patient, intermediate, greater than 3 minutes, up to 10 minutes Short descriptor: Tobacco-use counsel 3-10 min
C9802 – Smoking and tobacco cessation counseling visit for the asymptomatic patient, intensive, greater than 10 minutes
Short descriptor: Tobacco-use counsel >10min Claims for smoking and tobacco use cessation counseling services G0436 and G0437 shall be submitted with diagnosis code V15.82, history of tobacco use, or 305.1, non-dependent tobacco use disorder.
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 to report an E/M service with modifier -25 to indicate that the E/M service is a separately identifiable service from G0436 or G0437.
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes
(Rev. 2058, Issued: 09-30-10, Effective: 08-25-10, Implementation: 01-03-11) When denying claims for counseling to prevent tobacco use services submitted without diagnosis codes 305.1 or V15.82, contractors shall use the following messages: MSN 15.4: The information provided does not support the need for this service or item. MSN Spanish Version: La información proporcionada no confirma la necesidad para este servicio o artículo
RARC M64 – Missing/incomplete/invalid other diagnosis CARC 167 This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Contractors shall use Group Code CO, assigning financial liability to the provider, if a claim is received with no signed ABN on file.
When denying claims for counseling to prevent tobacco use services and smoking and tobaccouse cessation counseling services that exceed a combined total of 8 sessions within a 12-month period (G0436, G0437, 99406, 99407), contractors shall use the following messages: MSN 20.5: “These services cannot be paid because your benefits are exhausted at this time.” MSN Spanish Version: “Estos servicios no pueden ser pagados porque sus beneficios se han agotado.”
CARC 119: “Benefit maximum for this time period or occurrence has been reached.”
RARC N362: “The number of days or units of service exceeds our acceptable maximum.” Contractors shall use Group Code PR, assigning financial liability to the beneficiary, if a claim is received with a signed ABN on file. Contractors shall use Group Code CO, assigning financial liability to the provider, if a claim is received with no signed ABN on file.
The Common Working File (CWF) shall edit for the frequency of service limitations of counseling to prevent tobacco use sessions and smoking and tobacco-use cessation counseling services (G0436, G0437, 99406, 99407) rendered to a beneficiary for a combined total of 8 sessions within 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 counseling 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 counseling session was performed and count until 11 full months have elapsed. 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.