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Internal Medicine Coding Alert

Reader Question:

Tobacco-Use Cessation Counseling Criteria

Question: Aren't we allowed to bill for counseling for smoking cessation? If so, what codes are being used? What are the criteria that are used to determine coverage?

New York Subscriber

Answer: CMS provides coverage for smoking and any other tobacco-use cessation counseling. Earlier, only beneficiaries who were diagnosed with a tobacco-related condition or those with symptoms of a tobacco-related condition were covered. However, from Aug. 25, 2010, the tobacco-use cessation counseling has been extended even to people who are not currently showing any signs or symptoms of any tobacco-related condition.

The coverage for counseling includes two attempts at cessation. In each attempt, only four counseling sessions will be covered. So, in one year, a total of eight sessions will be covered. 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 Medicare-covered cessation counseling session was performed. For example, if the patient received the first of eight covered sessions in January 2011, then the count starts beginning February 2011, and the beneficiary is eligible to receive a second series of eight sessions in January 2012.

Depending on the time spent for the counseling sessions for an asymptomatic Medicare patient, you can report it as G0436 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes) or G0437 (Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes) for patients that come under the purview of Medicare. For all other insurance payers who do not follow Medicare guidelines and for symptomatic Medicare patients whom you are counseling therapeutically (rather than preventively, as with G0436 and G0437), you can report 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes).

Tip: The following are the criteria to determine coverage for tobacco-use cessation counseling:

  • Coverage is provided to those who are currently using tobacco in any form and have a tobacco-related condition or are currently showing symptoms of a tobacco-related condition
  • Coverage is also provided to any asymptomatic patient who uses tobacco in any form
  • The person who receives counseling should be alert and competent when the sessions are provided
  • The counseling should be performed only by a qualified physician or a practitioner who is recognized by Medicare to provide these services.

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