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Thread: Preventive visits WITH tobacco cessation counseling

  1. #1
    Join Date
    Apr 2007
    Everett, WA

    Default Preventive visits WITH tobacco cessation counseling

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    One of our family care practices asked if it was required that we enter the ICD-9 code for tobacco abuse because it would trigger a "problem" visit that folks would have to pay in addition to their preventive visit (unless they had another disease state like COPD that applied). They wanted to know if perhaps the Preventive Medicine counseling codes of 99401-99409 could be utilized in a "general" sense, especially if they are counseling on a "multitude of things?" I've studied the submissions here on the forums and the helpful links provided.

    I'm new to Preventive Coding yet my radar is going off and warning "no, this can't be done" because it violates the rules of specificity. Furthermore, it clouds the issue of documentation and I'm having a difficult time with that. Comments?

    And then, there's the issue of "carve outs". Yikes!! A general preventive exam in addition to a problem exam on the same date of service falls within this spectrum, correct?

    I'd like answers in regards to BOTH commercial and MCR policies, and apologize in advance if this post needs to supply additional specifics. Direction from my colleagues, please?
    ---Suzanne E. Byrum, CPC

  2. #2
    Join Date
    Apr 2007
    North Carolina


    I agree with you Suzanne. As is stands now, MCR only pays for tobacco cessation when it is documented to be "reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use, or who is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on FDA-approved information."

    Tobacco abuse disorder is not payable by MCR and would become patient responsibility (carved out as you mentioned). To submit a claim with any other diagnosis for payment purposes would result in a false claim (IMHO).

    The good news....

    Medicare is reviewing their current policy and proposing to pay for tobacco abuse cessation as a preventative measure.

    CMS proposes to cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:

    -Who use tobacco, regardless of whether the patient has signs and symptoms of tobacco-related disease;

    -Who are competent and alert at the time that counseling is provided; and

    -Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

    Current Policy-

    Proposed policy-

  3. #3


    Just an note that these tobacco codes 99406 and 99407 have specific guidelines.

    Please look at the specifics expected for these codes including: assessement of willingness to change, barries to changing behavior, counseling, f/up etc. This is all explained in the CPT notes in the section just before these codes.

    These codes must meet and the documentation must support the "significant separate service" guidelines when coded/billed with another E&M service

    The reason I mention this, is I have found common errors:
    1) documentation does not support a separate service
    2) time is not documented
    3) documentation does not meet the CPT guidelines

    The physician documenting at the end of his Preventive note "spent 5 minutes counseling patient on smoking cessation" does not meet or support coding/billing the 99406

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