Smoking Cessation CMS Coding and Reimbursement Policies

1
Smoking CessationCMS Coding and Reimbursement
Policies

• ASA Smoking Cessation Task Force
• Sharon Merrick, CCS-P
• Coding and Reimbursement Manager
• Stan Stead, MD MBA
• Chair, ASA Committee on Economics

2
Who is covered?

• Medicare beneficiaries who
• Use tobacco and have a disease or adverse health
  effect found by the US Surgeon General to be
  linked to tobacco use, or
• Take certain therapeutic agents whose metabolism
  or dosage is affected by tobacco use as based on
  FDA-approved information

3
Provider Training and Certification

• In Decision Memo for Smoking and Tobacco Use
  Cessation Counseling (CAG-00241N), CMS states
• CMS understands that experts and stakeholders in
  the tobacco control community are working toward
  a consensus with respect to this goal.
  Therefore, as standards are developed for
  training, we encourage clinicians to become
  appropriately credentialed. CMS plans on
  reviewing these standards and may add training
  requirements in the future.

4
Cessation Counseling Attempt

• Cessation counseling attempt occurs when a
  qualified physician or other Medicare-recognized
  practitioner determines that a beneficiary meets
  the eligibility requirements above and initiates
  treatment with a cessation counseling attempt.
• A cessation counseling attempt includes up to 4
  cessation counseling sessions
• (1 attempt up to 4 sessions).

5
Cessation Counseling Attempt

• Two cessation counseling attempts (or up to 8
  cessation counseling sessions) are allowed every
  12 months.
• In calculating the 12-month period, it is
  necessary for at least 11 months to have passed
  following the month in which the first
  Medicare-covered cessation counseling
  attempt/session was performed.
• Per CR4104, providers may query the CWF to see
  how many covered sessions a beneficiary has
  already received.

6
Cessation Counseling Session

• Face-to-face patient contact of either the
  intermediate (3 min and (10 min) type performed either by or incident
  to the services of a qualified practitioner for
  the purpose of counseling the beneficiary to quit
  smoking or tobacco use.
• During a 12-month period, the practitioner and
  the beneficiary would have the flexibility to
  choose between intermediate or intensive
  cessation strategies for each session.

7
Coding

• 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 visit
  intensive, greater than 10 minutes
• These codes became effective January 1, 2008
• No CCI edits linking these codes with 00100-01999

8
Coding

• ICD-9-CM
• 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 is
  affected by tobacco use.

9
Documentation

• Medical record should support
• The level of service provided, and
• That the coverage criteria were met.
• Services could be subject to post-payment review.

10
Payment

• In FY 2008, the unadjusted allowed amount when
  provided in a facility setting
• 99406 - Intermediate
• Non Facility Allowed Amount 12.19
• Facility Allowed Amount 11.43
• 99407 Intensive
• Non Facility Allowed Amount 23.99
• Facility Allowed Amount 22.85

11
Payment

• Deductible and coinsurance apply.
• Payment for non-assigned claims subject to
  Medicare limiting charge
• Patient responsibility limited to 115 of the
  allowed amount

12
Sources

• CMS Manual System
• Pub 100-03 Medicare National Coverage
  Determinations Transmittal 36
• Pub 100-04 Medicare Claims Processing Transmittal
  562
• Pub 100-04 Medicare Claims Processing Transmittal
  726
• MLN Matters
• MLN Matters Number MM3834
• MLN Matters Number MM4104