99406 CPT Code, CPT 99406, CPT code 99406, 99406

99406 CPT Code | Description, Guidelines, Reimbursement, Modifiers & Examples

The 99406 CPT code can be used for the diagnosis of drug consumption by a patient and treatment to change the patient’s behavior. In addition, CPT code 99406 may be billed for treating smoke-addicted patients. Medicare covers both outpatient and inpatient tobacco cessation counseling.

Medicare covers two attempts to quit smoking each year. Inpatients are only covered if the patient’s primary reason for being admitted is to receive tobacco use counseling.

E/M services necessitate intermediate or intensive counseling. Each session lasts three to ten minutes and divides into two or three sessions.

A licensed psychologist, clinical social worker, physician assistant, nurse practitioner, or clinical nurse specialist can provide services.

CMS does not currently require formal training, but this may change shortly. Counseling cannot offer over the phone; it will provide in person.

The CMS has developed new G codes to reduce tobacco use. Patients with symptoms can also receive tobacco cessation counseling using the CPT codes 99406 and 99407.

The patient only uses CTP code 99406 if they want to leave the drug and have the drug’s symptoms, especially smoking-related signs.

In addition to the diagnosis code for tobacco use, include additional regulations that detail tobacco use’s adverse effects, such as atherosclerosis or chronic obstructive bronchitis. Asymptomatic patients can use HCPCS codes G0436 and G0437 for smoking cessation counseling.

These services can provide and reported by any healthcare professional of any specialty. Tobacco abuse is the only diagnosis code that will use for these individuals. Keeping a written record of all decisions made and suggestions made is essential. 

CTP 99406 and CPT 99407 can not frequently apply to the patient, not the provider. CMS’s two attempts per year payment policy covers up to eight face-to-face visits in a calendar year.

G0437 refers to counseling for behavior modification for smoking-addicted patients that lasts more than ten minutes. It can recommend using tobacco for more than ten minutes; in the CTP code 99407, proper documentation and time factor counseling will also need for appropriate patient treatment.

99406 CPT Code Description

The CPT manual officially describes CPT 99406 as: “Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes.”

CTP code 99406 and CTP 99407 use structured screening, brief intervention for substance abuse, and two other principles for addiction treatment counseling. 

They “include individual valid and reliable treatments of evaluating readiness for change, barriers to change, providing specific suggested actions and motivational counseling,” according to the CPT manual.

 Patients who are drug addicted may not want to leave this drug. According to the CPT manual, these interventions include services and follow-up.

Smoking or substance abuse can treat with the help of these codes, which indicate what type of treatment they can use and how it will help prevent future health issues.

Time-based codes can use for both new and existing patients. There are multiple processing stages and two distinct collection methods to consider.

A standard questionnaire is required for these services to determine the patient’s substance abuse. The Alcohol Use Disorders Identification Test was created to assess patients’ alcohol consumption (AUDIT). 

When the score is eight or higher, it is safe to assume that the drinker has gone too far. The scale ranges from 0 to 40.

A score more excellent than 12 indicates substance abuse. Similarly, for observing the patients, some tests were developed in which participants responded by answering yes or no to 28 questions about drug use.

The doctor or non-physician practitioner discusses the importance of reducing intake with the patient, informs them of the screening results, and, if necessary, refers them to additional services.

Billing Guidelines

CMS permits the 99406 CPT code to be billed twice a year for individual smoking cessation counseling. During each session, the clinician and patient can choose between intermediate (three to ten minutes) and intensive (lasting ten or more).

Individuals who want to quit smoking or refrain from using alcohol or other drugs should seek assistance from a counselor or other intervention services. Patients or those at risk of illness or injury can connect these services to the issue.

Additional tools can use to assess the patient’s willingness to change behavior and to solicit feedback on a plan for implementing appropriate actions and motivations.

Medicare covers both outpatient and inpatient tobacco cessation counseling. Inpatients are only covered if tobacco use counseling is not the primary reason for the patient’s hospitalization. Medicare covers two quit attempts per year.

Intermediate or intensive counseling can require for E/M services. It can divide into two to three sessions of three to ten minutes. Intensive counseling consists of four sessions lasting more than ten minutes each. 

Counseling that is limited to one session and lasts less than three minutes is considered an E/M service and cannot pay separately. The E/M services involve sessions of counseling. Over a year, the total annual benefit covers eight sessions.

The smoking cessation services (99406 CPT code and 99407 CPT code) were developed as E/M services and can report alongside 99201-99205 and 99211-99215. They will be refused “IN” for all other E/M services (service incidental to the primary procedure, no patient liability).

 If the doctor performs a thorough preventative medicine evaluation on new (99381-99387) or established patients, smoking cessation counseling will also include in the service’s scope (99391-99397).

The following CPT codes can use to bill for smoking cessation services:

  • Visit CPT 99406 for tobacco cessation counseling. 
  • Intermediate: more than 3 minutes and up to 10 minutes
  • A session of more than ten minutes for intensive smoking and tobacco use cessation counseling (99407).

The patient’s medical file documentation can use to support the cessation code billing. The documentation should show a significant and identifiable service in addition to what will discuss in counseling.

Payers frequently reimburse preventive service codes, but reimbursement varies, particularly for organizations or providers participating in unique payment arrangements such as discounted rates or other value-based payment plans.

As previously stated, preventive codes can apply to both individuals and groups. However, preventive principles cannot apply to counseling sessions that last less than three minutes; instead, this time will include the E/M of the office-based visit, and the corresponding preventive codes are not applied.

99406 CPT Code And Modifier 25

CPT code 99406 can be reported with modifier 25. CPT 99406 and CPT 99407 can be billed separately for initial and follow-up visits. Preventive codes cover services that include risk reduction as part of the prevention process (for ongoing patients).

As a result, insurance may not cover other principles, such as nicotine and tobacco addiction counseling. CTP code 99406 uses modifier 25 for the evaluation and management services to the payer.

Services provided under the prevention E/M code must be differentiated and documented when using the codes 99406 or 99407. Therefore, adding a modifier 25 to the primary E/M visit code may be beneficial.

In 2016, prevention services guidelines will revise to clarify behavior change interventions and preventive visits. According to the guidelines, it is distinct from evaluation and management (E/M), and the modifier 25 can use for the reimbursement process of the CTP code 99407.

The subject matter, specifics, and duration of counseling can document in the medical record. It can previously state in Section 1 that it is critical to link each E/M code with the correct diagnosis code.

The evaluation and management services will also help patients control their smoking addiction. Modifying behavior and counseling can also significantly affect the patient’s behavior, and regular counseling can substantially impact the patient’s behavior.

Providers may use a single counseling code only once per visit. The patient’s needs can also consider met in a way that is directly related to the regulations. Parental counseling, for example, is not billable by providers for pediatric patients.

Follow-up time will schedule for the amount of time allotted to patient counseling. To meet the requirements for medical necessity or to be able to bill the codes, it is not enough to note in the medical file that the doctor spent 11 minutes discussing tobacco use with the patient. 

Modifier 25 will add to the E/M code to distinguish it from the behavior change intervention service. Code 99406 is assigned to counseling sessions lasting four to ten minutes, while code 99407 gives to sessions lasting more than ten minutes.

Reimbursement For CPT 99406

Medicare pays $28.96 for longer-term smoking cessation counseling under CPT code 99407. The reimbursement for CPT 99406 is $15.70 for sessions lasting 3 to 10 minutes.

These are national reimbursement rates; however, Medicare payments in your area may vary. In some cases, a 10-minute or more extended consultation may be unnecessary.

Example 1

A long-term Medicare patient reports wheezing and shortness of breath to his primary care physician.

The patient appeared to have smoked and developed chronic bronchitis, which the doctor documented in a Level 4 visit (40 pack-years). CPT 99406 may be reported in this case.

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