Contrary to popular misconceptions, mechanisms for compensating clinicians for tobacco dependence treatment services do exist.
The use of imprecise language surrounding smoking and tobacco has led to several unfortunate misimpressions over the years. The prevailing notion that “smoking cessation is not paid for” is strictly true when referring to publicly provided lay counseling such as quit lines, community groups, etc. However, cognitive services provided by physicians are reimbursable, irrespective of the problem to which they are applied.
While the specifics of tobacco treatment reimbursement vary by both insurer and contract, as a general rule, clinicians should expect to be fairly compensated for tobacco use treatment services, in a manner similar to compensation for services delivered for other problems. Because tobacco use treatment represents a special circumstance with overlapping behavioral and biological dimensions, it is important to understand the basic structure of the compensation model in order to ensure that billing practices are consistent with prevailing requirements and definitions. This section of the Tool Kit provides a general framework of coding and billing principles relevant to tobacco use treatment, intended to help practice managers overcome practical obstacles to the provision of care.
In addition to describing the framework for compensation, this section offers sample cases and highlights caveats wherever appropriate. Though accurate in a general sense, the Tool Kit examples are intended only as a guide, and should not be interpreted as a guarantee of payment. When discrepancies exist, contact payer representatives for specific plan details and definitive guidance.
First question: Is it counseling? Or is it management?
Because tobacco use treatment relies in large part on good communication and an effective therapeutic relationship, there can be substantial confusion over whether what we do in the office should be considered counseling or management. Imprecision in usage frequently leads to synonymous connotations. While either of these services can be provided within a clinical encounter, there is a typological distinction between these two services that may be useful in deciding which coding and documentation requirements apply.
Evaluation refers to the cognitive processes applied while determining the significance or status of a problem or condition. This is typically accomplished through careful appraisal and study. As an example, the elements of evaluation in general medical practice might include a careful history, a review of systems, X-ray testing, or the physical exam. Similarly, evaluation requirements for tobacco use often include a careful evaluation of variables such as severity of nicotine dependence, the severity of confounding co-morbidities, the likelihood of downstream toxic effects of prolonged exposure, the patient’s insight into the problem and his or her confidence in abstinence, prior experience with cessation, or response to your recently prescribed interventions.
Management refers to the conduct or supervision of activities in pursuit of a pre-specified end. This often implies that the plan be based on the results of the evaluation, and that it includes the judicious use of multiple means to that end. As an example, the management plan for a severe asthmatic in exacerbation might include the decision to begin systemic steroids and the advice to avoid environmental triggers, and might be based on information garnered through historical, physical, and radiographic evaluation. Similarly, management decisions in the tobacco dependent patient might include medication or environmental modification recommendations, and are typically based on information garnered through historical, physical, or standardized instrument evaluation (e.g., screening for depression).
Counseling refers to the professional guidance provided to an individual. Though the typical connotation of counseling implies the utilization of psychological methods, counseling often happens in medical practice disguised as patient education. For example, physicians often use various techniques of personal interview during the collection of case data, including testing interest and aptitude, in an attempt to find the optimal way to transmit information or direction. In asthma, instruction on proper inhaler technique, or on environmental management, might be considered counseling. In tobacco use treatment, similar examples might include a discussion of potential triggers, or suggestions on stress management techniques.
Within this construct, counseling may be considered a subset of the cognitive services typically employed during management, such that:
Readers are referred to Coding for Chest Medicine 2009 published by the American College of Chest Physicians for specific coding details and definitions. 8Counseling services (also referred to as Behavior Change Interventions) are services that are provided directly by a physician or other qualified healthcare professional for the purpose of promoting health or preventing injury. These are distinct from the more typical evaluation and management (E/M) services, and may be reported separately when performed. Behavior change interventions are for persons who have a condition that may be considered a disease unto itself, including tobacco use, obesity, or substance abuse. Separate and distinct E/M services may be provided on the same day but, in this case, the time spent providing the counseling services may not be included as a basis for the E/M code selection.
Case Example 1: The Tobacco Dependence Evaluation and Management Visit
Mrs. Smith presents to your office on referral from a colleague. She is referred for help with her current tobacco use, totaling approximately 20 cigarettes per day for over 30 years. Your history focuses on details of her tobacco use patterns to date, including a fuller understanding of previous quit attempts, triggers to smoking, and the nature of her reluctance to quit. The review of systems reveals that Mrs. Smith often feels short of breath with 1 flight of steps, and your exam reveals coarse rhonchi in bilateral lung fields. Office evaluation procedures are performed, including administration of Fagerstrom’s test for nicotine dependence (FTND), administration of a depression screening instrument, and evaluation of spirometry before and after bronchodilator administration. By your evaluation, the patient appears to suffer from severe nicotine dependence, has a high likelihood of major depressive disorder in the recent past, and has mild irreversible airflow obstruction. Based on these insights, you determine the most appropriate pharmacologic and non-pharmacologic interventions, and begin developing a plan with the patient. After some discussion, the final plan is agreed upon and you confirm the patient’s level of understanding and concurrence with the plan. You set a return visit appointment for 3 weeks from today in order to check response to medications, barriers to adherence, and any potential side effects.
Though there is a modest amount of patient education and counseling integrated throughout the visit, the evaluative nature of the encounter is manifest in several ways. The results of this evaluation were used to formulate a plan that included an iterative reassessment of the effectiveness of the recommendations.
Case Example 2: The Tobacco Dependence Counseling Visit
Last week, Mr. Jones presented to your office for evaluation and management of a mild COPD exacerbation. At that visit, he expressed an interest in quitting, but neither you nor he were prepared to engage in more than a superficial discussion of smoking at that time. Because Mr. Jones has smoked nearly 2 packs of cigarettes daily for 45 years, you decided to ask Mr. Jones to return for a more prolonged and meaningful discussion in about one week. Today, Mr. Jones returns to learn more about his cessation options. During today’s visit, you reviewed the relevance of Mr. Jones’ smoking to his current medical condition, offered him some advice on the proper use of the nicotine patch, and discussed available mechanisms for extra-treatment support, including calls to the national quit line 1 800 QUIT NOW. He was able to appropriately reflect back his understanding of the problem and expressed an actionable plan to attempt cessation. You arrange for a follow-up visit in your office in two weeks with the intention of assessing his progress and making further recommendations.
This visit is characterized by the near exclusive focus on patient education and counseling. While it may have included a perfunctory assessment of his physical progress since last week, the purpose of the visit is clearly to address several manifest educational needs. The evaluative functions in this visit are limited to concepts such as testing of beliefs, assessment of understanding, and articulation of subsequent steps.
Case Example 3: Combined E/M and Tobacco Dependence Visit
Mr. Doe presents to your office for follow-up evaluation and management of cough. The visit focuses on the progress made in the diagnosis and management of the cough, including an assessment of response to therapy and a review of relevant radiographs. During the visit, he is once again engaged in a discussion regarding the relevance of cessation to his overall health. He expresses an interest in quitting, but is not willing to commit to a stop date at this time. At the conclusion of the cough visit, you use the final five minutes to discuss the barriers to cessation, and make some recommendations on appropriate pharmacotherapeutic options for Mr. Doe to consider.
The dominant theme of this visit is the evaluation and management of cough. During the visit, an opportunity to address smoking presented itself, and additional time was spent focused on tobacco use treatment.
Next question: What is the level of service?
Evaluation and Management (E/M) services
For most Evaluation and Management visits, clinicians will refer to the American Medical Association CPT Guidelines and Procedures Manual (CPT)9to identify the correct level of service through the algorithms that relate elements of history, physical exam, and complexity of clinical decision making. When it comes to treating tobacco dependence however, the actual level of cognitive service provided to the patient during the visit may not be neatly reflected by the standard E/M rubric. For example, the clinician may actively choose to forgo evaluating several systems on physical exam in favor of gaining more insight into tobacco use patterns and obstacles to cessation. Irrelevant details of the family history may be omitted in favor of evaluating concurrent substance abuse potential.
Case Example 1: The Tobacco Dependence Evaluation and Management Visit
In the event that the primary goals of the visit relate directly to the diagnosis/confirmation and management of tobacco use and related complications, clinicians may elect to code the visit using the appropriate E/M service codes that relate to the type and duration of the visit, as long as the time dedicated to tobacco treatment counseling exceeds 50% of the total visit time. In this case, documentation is necessary to highlight the distinction between the behavioral change intervention and the more robust evaluation and management services. For example, comments should include reference to the subjective and/or objective evaluation of nicotine dependence (Patient Assessment), evaluation of potential concurrent co-morbidities (e.g., depression, treatment contraindications, etc.), as well as their potential impact on management decisions. Education efforts regarding the nature of tobacco use, treatment strategies, and possible side effects should be documented, as should the patient’s response to the discussion. The plan for treatment should be outlined, including any contingency planning discussed with the patient. These details help to establish the evaluative nature of the visit, as well as the more complex and iterative nature of longitudinal management. The level of service can be determined using time thresholds (Table 1) as long as the note clearly documents 1) the time dedicated to counseling, 2) that the total time of the visit exceeded the threshold, 3) that counseling activities occupied more than 50% of the total visit time, and 4) counseling details. It is acceptable for clinicians to use clear and concise notation to document these facts instead of long or cumbersome prose, for example: “Total 25 min / counsel 15 min.”
Table 1 – Time thresholds (in minutes) that define levels of service per visit category.
|Code Range||<p”>Level 1||Level 2||Level 3||Level 4||Level 5|
|Outpatient Consultation||99241 – 99245||15||30||40||60||80|
|New Patient||99201 – 99205||10||20||30||45||60|
|Established Patient||99211 – 99215||5||10||15||25||40|
Case Example 3: Combined E/M and Tobacco Dependence Visit
Frequently, clinicians are faced with a visit that starts off focused on a different problem, but comes to include a discrete focus on tobacco. In this case, two options are available for coding the level of service. For visits in which the overall counseling time exceeds 50% of the total time dedicated to the visit, the level of E/M service may be calculated based on the time thresholds listed in Table 1. In this case, all elements of counseling, including for example the time spent educating the patient on the diagnostic considerations of cough, should be included when calculating the proportion of counseling time for the visit. Conversely, if the time spent in counseling does not exceed 50% of the total visit time, the clinician may elect to code for the two component services separately. That is to say that the level of E/M services may be based on the standard CPT rubric, with the additional counseling service coded using the Behavior Change Intervention codes listed below.
Caveat: In many practices, the evaluation and management of cough may prompt a “referral” to the nurse practitioner at the conclusion of the visit for more complete counseling services. Remember that smoking cessation counseling services can be provided on the same day as E/M services, either directly by the physician or by other qualified healthcare professionals. However, the time spent providing the counseling services may not be included as a basis for a single E/M code selection. Report the E/M visit separately from the behavioral health intervention, if guidelines for each service are met. When an office visit (e.g., 99213) and smoking cessation counseling (e.g., 99407) are reported on the same day, append modifier 25 to the E/M (e.g., 99213-25)
Counseling services – Behavior Change Interventions
Medicare and Medicaid deem smoking cessation counseling to be reasonable and necessary for individuals who have evidence of conditions linked to tobacco. Clinicians should consider using the counseling codes when tobacco use treatment can be viewed as a portion of, or adjunct to, the primary purpose of the visit. For example, in a patient who presents for evaluation and management of COPD, cessation counseling would be considered a core component of their care, but may not be the main focus of the interaction.
Cessation counseling that lasts less than 3 minutes is considered to be part of the standard E/M service for the underlying condition. For patients who require additional counseling, the clinician may also report intermediate (3-10 minutes) or intensive (greater than 10 minutes) of service. Effective January 1, 2008 Medicare implemented two new CPT codes to reflect these services: 99406 for intermediate counseling, and 99407 for intensive. These codes replace the previous G codes.
Case Example 2: The Tobacco Dependence Counseling Visit
Medicare requires that the medical record include some documentation of the necessity of this service, which may include reference to a condition or therapeutic agent that is being adversely affected by tobacco use. Comments in the record should document both the time spent in counseling, as well as pertinent details of the cessation strategies discussed. Medicare has assigned intermediate counseling (99406) 0.24 work Relative Value Units (RVU), and intensive counseling (99407) 0.5 work RVU. 99406 cannot be reported in conjunction with 99407. Medicare will cover two attempts at smoking cessation each year, with each attempt consisting of a maximum of four sessions (any combination of intermediate and/or intensive).10
Caveat: Remember that Medicare covers and reimburses this service, while other payers may not. Private insurers may place Behavior Change Interventions within their behavioral health services carve out, in which case reimbursement for these services is not available to other clinicians. When the insurer denies payment for smoking cessation counseling, the financial responsibility for the charges may fall to the patient.
Last question: Which diagnosis is which?
Readers are referred to the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM)11 for complete descriptions of diagnostic codes relevant to tobacco use treatment.
Selection of Primary Diagnosis:
Healthcare providers are expected to determine the primary diagnosis based on the condition most related to the current plan of care. The diagnosis may or may not be related to the patient’s chief complaint or reason for presentation. The primary diagnosis must relate to the services rendered, and to the documentation of the visit details.
Selection of Secondary Diagnosis:
Secondary diagnoses remain defined as “all conditions that coexisted at the time the plan of care was established, or which developed subsequently, or affect the treatment or care.” Secondary diagnoses may include conditions actively addressed in the patient’s plan of care as well as any co-morbid conditions that affect treatment decisions. Avoid listing diagnoses that are of mere historical interest and without impact on patient progress or outcome, or for which the physician does not mention a course of action.
Caveat: There is a subtle difference between Nicotine Dependence (305.1) and Toxic Effects of Tobacco (989.84). Nicotine dependence refers to the addictive nature of tobacco use. Strictly speaking, the evaluation and management of addiction may be considered the purview of behavioral health professionals, and may be subject to behavioral health contractual restrictions when used as the primary justification for the E/M visit. Toxic Effects of Tobacco (989.84) refers broadly to the set of untoward downstream consequences of tobacco use, within which dependence may be included. Within medical E/M encounters that relate primarily to tobacco, it may be most appropriate to list Toxic Effects of Tobacco (989.84) as the primary justification for the visit, and include the relevant related diagnoses and symptoms, for example Nicotine Dependence (305.1), COPD (496), or Cough (786.2), as the secondary diagnosis codes. It is best to note the related condition(s) as “resulting from” or “the toxic effect” of tobacco use. This best supports use of 989.84 when the documentation is internally or externally reviewed.
Caveat: Medicare guidelines allow Nicotine Dependence (305.1) to be used as the primary diagnosis code when reporting Behavioral Health Interventions, both intermediate (99406) and intensive (99407) services. Secondary diagnoses that reflect the related disorders or symptoms being affected by tobacco use should also be included to reflect the composite health concerns that prompted the counseling service. Current regulations prohibit Nicotine Dependence (305.1) from being used as the primary diagnosis for inpatient services.
2009 Pulmonary PQRI performance measures
The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). The Centers for Medicare and Medicaid Services (CMS) named this program the Physician Quality Reporting Initiative (PQRI). Pay for performance initiatives are developed in nearly all sites of service, and focus on the delivery of quality medical services. CHEST encourages all eligible practices to participate in PQRI.12
In December 2008, CMS finalized the list of performance measure specifications for their 2009 initiative, which began January 1, 2009. Two measures specific to tobacco use are included in this initiative. Specifications for these measures are detailed on the CMS Web site and are available at [www.cms.hhs.gov/pqri] under “Codes/Measures.” Denominator codes are the universe of eligible cases. The numerator quality-data codes (QDC) are the related CPT Category II codes listed below.
PQRI Measure #114: Inquiry Regarding Tobacco Use
Description: Percentage of patients aged 18 years or older who were queried about tobacco use one or more times within 24 months. Report a minimum of once per reporting period for all patients seen during the reporting period.
Use codes: CPT II 1000F Tobacco use assessed (only modifier 8P)
CPT II 1034F Current tobacco smoker, or
CPT II 1035F Current smokeless tobacco user, or
CPT II 1036F Current tobacco non-user
PQRI Measure #115: Advising Smokers to Quit
Description: Percentage of patients aged 18 years and older who are smokers and who received advice to quit smoking. Report a minimum of once per reporting period for all patients (whether or not they currently use tobacco) seen during the reporting period.
Use codes: CPT II G8455 Current tobacco smoker
CPT II 4000F Tobacco use cessation
intervention: counseling, or
CPT II 4001F Tobacco use cessation
intervention: pharmacologic therapy, or
CPT II G8456 Current smokeless tobacco user, or
CPT II G8457 Current tobacco non-user
Examples of successful systems
Veterans Health Administration (VHA) Codes (Appendix A).
Despite its effectiveness, tobacco-dependence counseling has been “widely underutilized in the VA healthcare system and other systems nationally.”13, 14 In an effort to increase the utilization of these services, the VA instituted several important policies intended to reduce or remove obstacles to care.
Beginning in 2003, the VA lifted prescribing restrictions on tobacco-dependence medications, making them more easily prescribed without the need for referral to a tobacco-dependence specialist.15 Tobacco-dependence pharmaceuticals are available at the standard pharmacy benefit co-pay.
For outpatient tobacco-dependence treatment visits, VA physicians use the same standard diagnostic (ICD-9-CM) and procedural (CPT) codes as non-VA healthcare providers. Effective May 2, 2005, physicians have the ability to eliminate the visit co-payment requirement for these visits and provide group or individual counseling without cost to the patient.13, 14The physician or care provider uses the following STOP codes to remove the co-payment for counseling.13
533707 Smoking Cessation Counseling – Individual
566707 Smoking Cessation Counseling – Group
The elimination of the co-pay for patients receiving counseling removes a potential barrier for any tobacco-dependent patient who expresses interest in stopping smoking. Providing no-cost counseling increases patient use fourfold and those counseled are four times more likely to quit.14
Starting in January 2007, the Veterans Administration System revised its performance requirements, mandating that VA physicians not only advise all patients to stop smoking, but also offer and provide effective treatment, including counseling and pharmacotherapy, for tobacco dependence.15
Kaiser Permanente of Northern and Southern California (Appendix B).
Based on the cumulative evidence confirming a tremendous cost savings to health maintenance organizations, Kaiser Permanente of Northern California substantially liberalized its tobacco-dependence treatment formulary in 2003. Kaiser beneficiaries can now receive any FDA-approved tobacco-dependence medication in any dose and combination deemed necessary by the physician. Moreover, pharmacotherapy may be continued without restriction on treatment duration, if determined necessary for preventing relapse.
Tobacco-dependence medications currently on formulary include nicotine patch, nicotine gum, nicotine lozenge, and bupropion SR. Though non-formulary, the nicotine inhaler, nicotine nasal spray, and varenicline are available as a covered benefit if the physician enters the appropriate “exception code” on the prescription.
Patients receive the pharmacy benefit at the standard co-pay rates by enrolling in one of the many behavior modification options offered. Kaiser Permanente of Northern and Southern California effectively eliminated barriers to effective treatment by providing patients with access to resources including telephone counseling, web-based cessation, and multisession group counseling programs, based on individual preference.
Caveat: A 2005 Centers for Disease Control (CDC) survey found that 75% of state Medicaid plans will cover at least one form of tobacco-dependence treatment (i.e., medication or counseling) for their beneficiaries upon physician prescription at either no cost or a modest medication co-payment, although for close to one quarter of states, medication coverage depended on enrollment in a behavior-modification program or participation in smoking-cessation counseling.16 In the 2006 CDC survey, the percentage of state Medicaid plans covering tobacco-dependence treatment increased to 76.5%; however, measures limiting their use also increased, “including measures that were inconsistent with the guideline (i.e., copayments, stepped-care approaches, requirements for enrollment in counseling to obtain medication, limitations on number of treatment courses, and not allowing combined treatments).”17 Many commercial insurance carriers have similar programs. Pediatric health care providers can code for tobacco-dependence treatment services for children or their parents under the same diagnosis codes as adult health care providers.
A call to action
Insurers often adopt coverage policies similar to those of Medicare. With tobacco dependence however, there is variability in coverage detail. Policies that limit reimbursement, carve out tobacco use treatment to a small subset of clinicians, or otherwise obstruct access to effective therapies represent unsound medical policy. Physicians are in a powerful position to create change by acting at the public health and public policy levels.18 Those interested in engaging in policy debates can do more than simply relay facts about tobacco and health to insurers. Engaging payers in discussion about coverage policies provides the opportunity to impact accessibility of tobacco use treatments, and is likely to be synergistic with efforts to help smokers quit within the office. Physicians who take steps to engage in local public health initiatives are likely to magnify the effects of their efforts at the bedside.19
Treating tobacco dependence is exceptionally cost-effective. As intensity of treatment goes up, the cost per quality adjusted life-year (QALY) saved goes down. On average, it costs only $3,539 per year of life saved, and as little as $1,108 when intensive treatment is provided.20 This compares favorably to other more expensive but common interventions, including HIV pharmacotherapy, renal transplantation, heart transplantation, treatment of hyperlipidemia, annual mammography, and even hypertension screening and pharmacotherapy.20, 21 (e.g., See Table 2). Tobacco-dependence costs are recovered in approximately 9 months.22, 23
Cost-Effectiveness Comparison of Tobacco-Dependence Treatment with Common Medical Tests and Interventions
Medical Screening Tests or Interventions
|Cost per Year of Life Saved20, 21|
Tobacco dependence (minimal intervention)
Postmyocardial infarction thrombolytic therapy
1. Create pre-printed encounter forms and fee slips that
include the relevant tobacco dependence treatment
codes alongside other common practice codes.
2. Encourage good communication on coding and
reimbursement issues; monitor reimbursement by
insurer and identify patterns / requirements early.
3. Query payer policies for varying coverage and coding
instruction. Although Nicotine dependence (305.1)
is the preferred ICD-9-CM diagnosis code for
counseling services, other third party payers may
reserve 300-level codes for behavioral health professionals.
Using 305.1 as the primary diagnosis can result in claim
denial if employed by a non-behavioral health clinician.
4. Keep good medical records. Review documentation of
tobacco dependence E/M and counseling services to ensure
that your notes meet documentation requirements for
counseling time spent with the patient.
5. Continue to advocate for reimbursement from insurance
carriers who do not currently support tobacco-dependence
6. Tobacco-dependence treatments are eligible expenses
under many flexible spending account (FSA) plans, enabling
patients to use pretax dollars to pay for health care expenses.