Billing & Reimbursements

Coding Reference

As of January 2014, the Affordable Care Act (ACA) requires insurance plans to cover many clinical preventive services. Some of the covered preventive services include:

1. Tobacco use screening for all adults
2. Tobacco cessation counseling for adults who use tobacco, and expanded counseling for pregnant women

Medicare

Medicare Part B covers both intermediate and intensive levels of tobacco cessation counseling for symptomatic and asymptomatic patients.

Two cessation attempts are covered per year, and both coinsurance and deductibles are waived. Each attempt may include a maximum of four intermediate or intensive counseling sessions. The total annual benefit covers up to eight smoking cessation counseling sessions in a 12-month period. The patient may receive another eight counseling sessions during a second or subsequent year after 11 months have passed since the first Medicare-covered cessation counseling session.

To qualify for payment from Medicare, the following criteria must be met at the time of service:

• Patients must be competent and alert.
• Counseling must be provided by a physician or other Medicare-recognized practitioner.

Symptomatic Patients

Symptomatic patients are those who use tobacco and:

• Have been diagnosed with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use.
• Take a therapeutic agent for which the metabolism or dosing is affected by tobacco use, based on information approved by the U.S. Food and Drug Administration (FDA).

Use the following CPT codes for symptomatic patients.

CODE	Type of Counseling	Description
99406	Intermediate	Smoking and tobacco-use cessation counseling visit greater than three minutes but not more than 10 minutes.
99407	Intensive	Smoking and tobacco-use cessation counseling visit greater than 10 minutes.

Asymptomatic Patients

Asymptomatic patients are those who use tobacco but do not have symptoms of a tobacco-related disease. Use the following CPT codes for asymptomatic patients.

CODE	Type of Counseling	Description
G0436	Intermediate	Smoking and tobacco use cessation counseling visit greater than 3 minutes but not more than 10 minutes.
G0437	Intensive	Smoking and tobacco use cessation counseling visit greater than 10 minutes.

Use the following CPT codes for patients who use tobacco but do not have symptoms of tobacco-related disease:

CODE	Description
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, other tobacco product, uncomplicated
F17.291	Nicotine dependence, other tobacco product, in remission
Z87.891*	Personal history of nicotine dependence

*For each patient receiving smoking and tobacco-use cessation counseling or counseling to prevent tobacco use, medical record documentation must show and include standard information along with sufficient patient history to adequately demonstrate that Medicare coverage conditions were met.

Medications

Medicare Part D covers FDA-approved cessation drug therapies. However, over-the-counter therapies are typically excluded.

Medicaid

Counseling

Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients. However, providers are encouraged to contact their state Medicaid office for coverage information in their specific state.

Medications

As of January 1, 2014, all state Medicaid programs are required to support all FDA-approved smoking cessation medications without requiring co-pays or other financial barriers.

Private / Commercial Insurance Carriers

Private insurers are required to provide evidence-based tobacco cessation counseling and interventions to all adults and pregnant women. Private payer benefits are subject to specific plan policies. Providers need to check with insurance plans to determine what specific interventions are included and the extent to which they are covered.

CODE	Type of Counseling	Description
99406	Intermediate	Smoking and tobacco-use cessation counseling visit greater than three minutes but not more than 10 minutes (Short Descriptor: Smoke/tobacco counseling 3-10).
99407	Intensive	Smoking and tobacco-use cessation counseling visit greater than 10 minutes (Short Descriptor: Smoke/tobacco counseling greater than 10).
S9075	Smoking Cessation Treatment
S9453	Smoking Cessation Classes	Non-physician provider, per session
99381-99397	Preventive Medicine Services	Comprehensive, preventive evaluation based on age and gender to include appropriate history, examination, counseling/anticipatory guidance, risk factor reduction interventions, and related plan of care
99078	Physician Educational Services	Group Setting (e.g., Prenatal, Obesity, Diabetes)

Various E/M services (associated with acute or chronic care) may be coded. When providing an E/M service, if greater than 50 percent of face-to-face time with patient is spent on counseling, time may be used as a basis for selection of level of service.

ICD-10 DIAGNOSIS CODE	Description
305.1	Tobacco-use disorder
649.0x	Tobacco-use disorder complicating pregnancy, childbirth or puerperium
989.84	Other substances, chiefly nonmedicinal as to source, tobacco*

• List additional code to specify nature of toxic effect. Excludes localized toxic effects classified elsewhere and respiratory conditions due to external agents and, if applicable, any diagnosis code(s) for condition(s) evaluated and managed in the same encounter.*
• All codes with .x or .xx require fourth or fifth digits. See the ICD-9 manual for complete descriptions.

*This list was formulated based on the 2004 Surgeon General’s Report on the Health Consequences of Smoking. It is not an all-inclusive list and may be subject to different interpretation of the report.

For a more comprehensive list of billing codes and information on how to use them, please see the American Lung Association’s Billing Guide for Tobacco Screening and Cessation here.

Self-pay Patients and Uninsured Patients

Resources for patients who do not have insurance coverage or who have limited coverage from their insurance carrier include the following:

• Quit lines (1-800-QUIT-NOW)
• Online cessation resources (Online Coaching)
• Flexible spending accounts if smoking cessation is an allowable expense
• Employee Assistance Programs (EAP); tobacco cessation may be covered by EAPs in some cases.
• Community resources and support groups
• Out-of-pocket spending

Last updated: 08/23/2018