Coding for Tobacco Screening and Cessation

Government Payors

Medicare

Medicare Part B covers two levels of tobacco cessation counseling for symptomatic and asymptomatic patients: intermediate and intensive. Two cessation attempts are covered per 12-month period. Each attempt may include a maximum of four intermediate or intensive counseling sessions. Therefore, the total annual benefit covers up to eight smoking cessation counseling sessions in a 12-month period.

The patient may receive another eight counseling sessions during a second or subsequent year once 11 full months have passed since the first Medicare-covered cessation counseling session took place. For counseling to qualify for Medicare payment, the following criteria must be met at the time of service:

• Patients must be competent and alert at the time of the counseling is provided.
• Counseling must be provided by a physician or other Medicare-recognized health care professional.

Symptomatic Patients

Symptomatic patients are those who use tobacco and:

• Have been diagnosed with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use.
• Take a therapeutic agent for which the metabolism or dosing is affected by tobacco use, based on information approved by the U.S. Food and Drug Administration (FDA).

Both cosinsurance and deductible apply. Reference codes for symptomatic patients.

Asymptomatic Patients

Asymptomatic patients are those who use tobacco but do not have symptoms of tobacco-related disease. Both coinsurance and deductible are waived. Reference CPT codes for asymptomatic patients.

Medicaid

Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients. For example, the ACA requires states to expand Medicaid coverage of cessation services for pregnant women. You are encouraged to contact your state Medicaid office for coverage information in your specific state.

The Centers for Medicare and Medicaid Services encourage state partners to support smoking cessation by ensuring coverage of all FDA-approved smoking cessation medication (prescription and over-the-counter [OTC]) without a copayment requirement or other financial barrier.

Private/Commercial Insurance Carriers

Private insurers are required to provide evidence-based tobacco cessation counseling and interventions to all adults and pregnant women. Private payer benefits are subject to specific plan policies. Check with individual insurance plans to determine what specific interventions are included and the extent to which these interventions are covered.

Self-Pay Patients and Uninsured Patients

Resources for patients who do not have insurance coverage or who have limited coverage by their insurance carrier include the following:

• Quitline: 1-800-QUIT-NOW (1-800-784-8669)
  
• Flexible spending accounts, if smoking cessation is an allowable expense
• Employee assistance programs (EAP), in some cases
  
• Community resources and support groups
• Out-of-pocket spending
• Online resources
• Centers for Disease Control and Prevention
  • How to Quit
  • Tips From Former Smokers
  • Quit Smoking
• U.S. Department of Health and Human Services
  • Smokefree.gov
  • SmokefreeTXT