Counseling to Prevent Tobacco Use (2021)

Medicare Part B already covers cessation counseling for individuals who:

1. Use tobacco and have been diagnosed with a recognized tobacco-related disease, or,

2. Use tobacco and exhibit symptoms consistent with a tobacco-related disease.

In addition to these effective for claims with dates of service on and after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries who do not have signs or symptoms of tobacco-related disease when the below conditions of coverage are met, subject to certain frequency and other limitations.

1. Who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease);

2. Who are competent and alert at the time that counseling is provided; and,

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

CPT and ICD to be reported for Tobacco cessation counseling

The CMS has created two new G codes for billing tobacco cessation counseling services to prevent tobacco use for dates of service on or after January 1, 2011. These are in addition to the two CPT codes 99406 and 99407 that currently are used for tobacco cessation counseling for symptomatic individuals.

G0436: Tobacco-use counsel 3-10 min

Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes.

G0437: Tobacco-use counsel >10 min

Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes.

Coinsurance and Copayment:

Medicare will waive the deductible and coinsurance / co-payment for counseling when billing with these two new G codes on or after January 1, 2011.

The diagnosis codes that should be reported with the aforementioned CPT codes are:

ICD-9: 305.1 (non-dependent tobacco use disorder), or

ICD-9: V15.82 (history of tobacco use).

Note: Claims submitted with the tobacco cessation counseling codes of G0436 and G0437, but which lack a required diagnosis code (305.1 or V15.82) will be denied with Claim Adjustment reason Code (CARC) 167 (This (these) diagnosis (es) is (are) not covered.

Frequency and Limitations:

CMS will allow two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate OR intensive sessions, with a total benefit covering up to 8 sessions per year per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than 3 minutes up to 10 minutes) or intensive (more than 10 minutes) cessation counseling sessions for each attempt.

Here is the information related to ‘The payment methods to institutional providers for outpatient services and claims processing information’.

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