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Modifier for 99407 smoking consultation

Cathi Posted Wed 30th of June, 2010 11:32:58 AM

I am billing '99407' with '99213' and getting denials. I have used the modifier '25' with '99213', but it seems to be asking for a modifier for the '99407'. Can anyone help me with this modifier?

Also I am using TOS '9' for consultation, would this be correct or should I be using TOS of '1'?

SuperCoder Answered Wed 30th of June, 2010 12:08:53 PM

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. 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.
Your TOS should be 1 (Medical care) not 9. I think this is the main cause for denial otherwise there should not be any issues with this claims. But, even if this is not accepted and paid then you need to call your insurance or consider this service as being part of E/M only.

Teresa Answered Wed 30th of June, 2010 14:13:59 PM

We use diagnosis codes 305.1 and V15.82 with the procedure codes 99406 and 99407. I use a different diagnosis for the office visit.
99213-25 DX: 440.22, 443.9
99406 DX: 305.1, V15.82
We do get payment from Medicare and Commercial carriers but we do not from Medicaid. Make sure the counseling is fully documented and the time documented in case they do ask for your office note.
Hope this helps. Have a good day.

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