How To Use CPT Code 4004F

CPT 4004F describes the screening of a patient aged 18 years or older for tobacco use and the provision of tobacco cessation intervention, such as counseling, pharmacotherapy, or a combination of both, if the patient is identified as a tobacco user. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 4004F?

CPT 4004F can be used to describe the screening of a patient aged 18 years or older for tobacco use and the provision of tobacco cessation intervention if the patient is identified as a tobacco user. This code is used when the healthcare provider assesses the patient’s tobacco use and offers counseling, pharmacotherapy, or a combination of both to help the patient quit using tobacco.

2. Official Description

The official description of CPT code 4004F is: ‘Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (PV, CAD)’

3. Procedure

1. The healthcare provider questions the patient aged 18 years or older about their tobacco use.
2. If the patient is identified as a tobacco user, the provider advises them to quit and assesses their willingness to attempt to quit.
3. The provider offers tobacco cessation intervention, which may include counseling, pharmacotherapy, or a combination of both, based on the patient’s preferences and needs.
4. The provider assists the patient with their chosen treatment option and supports them throughout the quitting process.
5. The provider documents the screening for tobacco use and the date of the screening in the patient’s healthcare record.

4. Qualifying circumstances

Patients eligible to receive CPT 4004F services are those aged 18 years or older who are screened for tobacco use. If the patient is identified as a tobacco user, they qualify for tobacco cessation intervention, which may include counseling, pharmacotherapy, or a combination of both. The healthcare provider must document the screening and the provision of tobacco cessation intervention in the patient’s healthcare record.

5. When to use CPT code 4004F

CPT code 4004F should be used when a healthcare provider screens a patient aged 18 years or older for tobacco use and provides tobacco cessation intervention if the patient is identified as a tobacco user. This code should not be used for patients under 18 years of age or for patients who are not screened for tobacco use.

6. Documentation requirements

To support a claim for CPT 4004F, the healthcare provider must document the following information:

• The patient’s age (must be 18 years or older)
• The screening for tobacco use
• If the patient is identified as a tobacco user
• The type of tobacco cessation intervention provided (counseling, pharmacotherapy, or both)
• The date of the screening
• The patient’s willingness to attempt to quit
• The patient’s chosen treatment option
• The provider’s assistance and support throughout the quitting process

7. Billing guidelines

When billing for CPT 4004F, ensure that the patient is aged 18 years or older and has been screened for tobacco use. Use the appropriate CPT code based on the type of tobacco cessation intervention provided (counseling, pharmacotherapy, or both). CPT code 4004F should not be reported with other codes related to tobacco cessation intervention. Ensure that the documentation supports the provision of tobacco cessation intervention and the patient’s identification as a tobacco user.

8. Historical information

CPT 4004F was added to the Current Procedural Terminology system on January 1, 2011. There have been changes to the code in subsequent years, including the addition of pharmacotherapy as a tobacco cessation intervention on January 1, 2012, and the inclusion of patients with peripheral vascular disease (PV) and coronary artery disease (CAD) on January 1, 2013.

9. Examples

1. A healthcare provider screens a 25-year-old patient for tobacco use and offers counseling to help them quit smoking.
2. A physician questions a 40-year-old patient about their tobacco use and prescribes pharmacotherapy to aid in their tobacco cessation efforts.
3. A nurse assesses a 60-year-old patient’s tobacco use and provides both counseling and pharmacotherapy to support their journey towards quitting.
4. A healthcare provider screens a 35-year-old patient for tobacco use and offers counseling and nicotine replacement therapy as tobacco cessation intervention.
5. A physician assistant questions a 50-year-old patient about their tobacco use and recommends a combination of counseling and medication to assist in quitting.
6. A nurse practitioner assesses a 45-year-old patient’s tobacco use and provides counseling and a prescription for a smoking cessation medication.
7. A healthcare provider screens a 55-year-old patient for tobacco use and offers counseling and a referral to a tobacco cessation support group.
8. A physician questions a 30-year-old patient about their tobacco use and provides counseling and information on nicotine replacement therapy.
9. A nurse assesses a 65-year-old patient’s tobacco use and offers counseling and guidance on the use of tobacco cessation medications.
10. A healthcare provider screens a 20-year-old patient for tobacco use and offers counseling and a referral to a tobacco cessation hotline.