Medicare Benefit for Tobacco Counseling
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- What is the Medicare benefit for tobacco counseling?
- Does this mean any smoker or tobacco user 65 or older can receive treatment for tobacco dependence?
- Which providers are authorized by Medicare to receive payment for services?
- What is the billing code?
- Can non-authorized Medicare providers who are providing tobacco dependence counseling on an OUTPATIENT basis be reimbursed incident to a physician's professional services?
- Can non-authorized Medicare providers who are providing tobacco dependence counseling on an INPATIENT basis be reimbursed incident to a physician's professional services?
- Is there any reimbursement for telephone counseling?
- Is there any reimbursement for group counseling?
- What is the fee schedule for this new benefit?
Q1. What is the Medicare benefit for tobacco counseling?
A: Medicare Part B covers 2 levels of counseling:
Intermediate, which covers tobacco-use cessation counseling from 3-10 minutes in duration,
Intensive, which covers tobacco-use cessation counseling greater than 10 minutes.
Coverage includes 2 attempts per year, each with a maximum of 4 intermediate or intensive sessions (a total of 8 sessions per 12 month period). This level of counseling can be billed in addition to a regular office visit using a modifier (described below). Medicare defines counseling for 3 minutes or less as minimal cessation counseling and this cannot be billed in addition to the Evaluation and Management (E&M) Code billed for a visit. Medicare Advantage Plans will cover all preventive services the same as Original Medicare.
Q2. Does this mean any smoker or tobacco user 65 or older can receive treatment for tobacco dependence?
A: Yes. Prior to August 25, 2010, coverage was limited to those tobacco users who were diagnosed with a recognized tobacco-related disease or had symptoms consistent with tobacco-related disease. This coverage remains intact.
After August 25, 2010, Medicare began to offer a preventive benefit and the counseling services were expanded to include those who do not have signs or symptoms of tobacco-related disease.
Q3. Which providers are authorized by Medicare to receive payment for services?
A: Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists and occupational therapists who are approved Medicare providers may provide services without direct physician supervision and bill directly for these services.
Cessation counseling sessions may be billed “incident to” the services of a qualified practitioner” using what is often referred to as a “nurse visit" code (99211). Billing 99211 is not always straightforward but can be appropriate in some circumstances, particularly if the physician has asked you to check up on the patient: [see pdf] AAFP Ask and Act Resources for Providing, Coding, Getting Paid for Tobacco Cessation Counseling
Q4. What is the billing code for tobacco cessation?
A: In January 1, 2008 the CPT codes for counseling Medicare recipients with tobacco related illness were changed to (subject to deductible): 99406 for moderate counseling of between 3-10 minutes; Short descriptor: Smoke/Tobacco counseling 3-10. 99407 for intensive counseling greater than 10 minutes; Short descriptor: Smoke/Tobacco counseling greater than 10. When billing for preventive cessation counseling in asymptomatic smokers, the following G codes are used (no deductible): G0436 for a visit of 3 -10 minutes G0437 for an Intensive visit >10 minutes For any counseling provided, it is best to document the actual time spent counseling in the visit note.
Q5. Can non-authorized Medicare providers who are providing tobacco dependence counseling on an OUTPATIENT basis be reimbursed incident to a physician's professional services?
A: According to “The Guide to Medicare Preventive Services” Third edition published by CMS (page 219). “Cessation counseling sessions may be performed “incident to” the services of a qualified practitioner. The Guide to Medicare Preventive Services is a useful resource and can be found here
Q6. Can non-authorized Medicare providers who are providing tobacco dependence counseling on an INPATIENT basis be reimbursed incident to a physician’s professional services?
A: As of August 25, 2010, Medicare began covering counseling to prevent tobacco use for both outpatient and hospitalized beneficiaries who use tobacco whether or not they have signs or symptoms of tobacco-related disease. The recipient of counseling must be competent and alert at the time that counseling is provided and the counseling must be provided by a qualified physician or other Medicare-recognized practitioner. Inpatients are covered only if counseling for tobacco use is not the primary reason for the patient’s hospital stay.
Q7. Is there any reimbursement for telephone counseling?
A: At this time, there is no reimbursement for telephone counseling. However, it is our understanding that Medicare will soon be publishing results of a study it conducted showing telephone counseling to be effective with Medicare beneficiaries. The North American Quitline Consortium is taking the lead in working with ATTUD and other organizations to advocate for coverage of telephone counseling. Phone f/up is considered by CMS as part of the care a qualified provider should provide and, as such, cannot be billed for. This extends to cessation via telephone – even a qualified, approved provider cannot bill for phone cessation services.
Q8. Is there any reimbursement for group counseling?
A: At this time, there is no reimbursement for group counseling. Although CMS found all forms of counseling to have significant effects on quitting, they found individual counseling to be the most effective and therefore decided not to reimburse for group (or telephone) counseling.
Q9. What is the fee schedule for this new benefit?
A: In recent years, the national average rate for Moderate Counseling (3-10 minutes), CPT Code 99406, ranges from $10.91 to 17.78 depending upon your facility and geographic area. Intensive Counseling (over 10 minutes), CPT Code 99407, is $22.34 to $36.95. For rates specific to your area, contact your local Medicare carrier.
Q10. What is ATTUD doing to advocate for this benefit and for reimbursement
A: ATTUD will continue to advocate for this coverage in all appropriate forums. It is unlikely that CMS will change their definition of qualified providers to include TTS anytime soon but this is one of the goals of implementing national certification. ATTUD continues to advocate for an extensive infrastructure of well-trained TTS who can provide this treatment in settings that include face-to-face, groups, and telephone counseling that follow evidence-based training standards. Currently this is being achieved by a growing number of accredited tobacco treatment specialist training programs.
Q11. Where can I find more information about this benefit?
Additional information is available through the Medicare Learning Network [read more]