Smoking CessationCMS Coding and Reimbursement Policies

ASA Smoking Cessation Task Force

Sharon Merrick, CCS-PCoding and Reimbursement

Manager

Stan Stead, MD MBAChair, ASA Committee on

Economics

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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

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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.

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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).

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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.

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Cessation Counseling Session

• Face-to-face patient contact of either the intermediate (>3 min and < 10 min) or intensive (>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.

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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

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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.

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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.

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Payment

In FY 2008, the unadjusted allowed amount when provided in a facility setting:

99406 - IntermediateNon Facility Allowed Amount $12.19

Facility Allowed Amount $11.43

99407 – IntensiveNon Facility Allowed Amount $23.99

Facility Allowed Amount $22.85

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Payment

• Deductible and coinsurance apply.• Payment for non-assigned claims subject to

Medicare limiting charge– Patient responsibility limited to 115% of the allowed

amount

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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

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• MLN Matters– MLN Matters Number MM3834– MLN Matters Number MM4104