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Medicare
Frequently Asked Questions
New Medicare
Benefit For
Tobacco Counseling
(Reviewed 5/2010)
This document has
been created to help provide you with some answers to common questions
that have risen due to the recent decision by the Center for Medicare
Services to cover counseling for tobacco. ATTUD will continue to post
additional information on this site as we get greater clarity around the
CMS decision. Please check back often. While we have tried to be as comprehensive
as possible in creating this FAQ resource it may not answer all your questions.
If you have a question that is not covered in this FAQ, please feel free
to post a question
to the ATTUD ListServ.
- What is the Medicare benefit for tobacco counseling?
- Does this mean any smoker or tobacco user 65 or older can receive treatment for tobacco dependence?
- Which providers are authorized by Medicare to receive payment for services?
- What is the billing code?
- Can non-authorized Medicare providers who are providing tobacco dependence counseling on an OUTPATIENT basis be reimbursed incident to a physician's professional services?
- Can non-authorized Medicare providers who are providing tobacco dependence counseling on an INPATIENT basis be reimbursed incident to a physician's professional services?
- Is there any allowance for inpatient tobacco counseling to be covered by auxiliary personnel?
- Is there any reimbursement for telephone counseling?
- Is there any reimbursement for group counseling?
- What is the fee schedule for this new benefit?
- Is this new benefit cast in stone, or will there be changes?
- What is ATTUD doing to advocate for this benefit and for reimbursement of TTSs?
- Where can I find more information about this benefit?
Q1. What is the Medicare benefit for tobacco counseling?
A: As of March 22, 2005, Medicare Part B began covering 2 new levels of counseling: intermediate, which covers tobacco-use cessation counseling from 3-10 minutes in duration, and intensive, which covers tobacco-use cessation counseling greater than 10 minutes. Coverage includes 2 attempts per year, each with a maximum of 4 intermediate or intensive sessions (a total of 8 sessions per 12 month period).
Q2. Does this mean any smoker or tobacco user 65 or older can receive treatment for tobacco dependence?
A: No. Coverage is limited to those tobacco users who have a “disease or adverse health effect caused or complicated by tobacco use” may take advantage of this new benefit. It also covers tobacco users who are being “treated with a therapeutic agent whose metabolism or dosing is affected by the use of tobacco.”
(Medlearn Matters Number MM3834, http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3834.pdf)Click on the titles to view Diseases and Health Effects Related to Smoking and Drug Interactions with Smoking. Adverse health effects of caused or complicated by tobacco use can be ascertained with a detailed medical and tobacco use history or objectively with medical diagnostics including (but not limited to) spirometry, chest radiology, lipid profiles, etc.
Q3. Which providers are authorized by Medicare to receive payment for services?
A: Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwifes, clinical psychologists, clinical social workers, physical therapists and occupational therapists “all have their own benefit categories and may provide services without direct physician supervision and bill directly for these services,” as long as the provider is legally authorized to perform services in the states in which they are furnished. (Medicare Benefit Policy Manual, Chapter 15, Section 60A.) According to “The Guide to Medicare Preventive Services” Third edition published by CMS (page 219).“Cessation counseling sessions may be performed “incident to” the services of a qualified practitioner.
The Guide to Medicare Preventive Services can be found at http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.
AAFP Resources Guide Members in Coding, Getting Paid for Tobacco Cessation Counseling
A: In January 1, 2008 the CPT codes were changed to 99406 for moderate counseling of between 2-10 minutes; Short descriptor: Smoke/Tobacco counseling 3-10. 99407 for intensive counseling greater than 10 minutes; Short descriptor: Smoke/Tobacco counseling greater than 10.
Q5. Can non-authorized Medicare providers who are providing tobacco dependence counseling on an OUTPATIENT basis be reimbursed incident to a physician's professional services?
A: According to “The Guide to Medicare Preventive Services” Third edition published by CMS (page 219). “Cessation counseling sessions may be performed “incident to” the services of a qualified practitioner.
The Guide to Medicare Preventive Services is a useful resource and can be found at http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
Q6. Can non-authorized Medicare providers who are providing tobacco dependence counseling on an INPATIENT basis be reimbursed incident to a physician’s professional services?
A: No. All inpatient Medicare services are paid by DRG—Diagnosis Related Group. The set DRG payment is modified by comorbid conditions and geographic location, rather than by specific service rendered. Thus, payment to the hospital would not change whether tobacco counseling were provided or not. These services are said to be “bundled”. It is still important for “nicotine dependence” to be included in the list of co-morbid conditions.
Q7. Is there any allowance for inpatient tobacco counseling to be covered by auxiliary personnel?
A: As far as we understand the benefit, the answer is no, services performed ‘incident to’ a physician referral are not billable in the hospital setting.
Q8. Is there any reimbursement for telephone counseling?
A: At this time, there is no reimbursement for telephone counseling. However, it is our understanding that Medicare will soon be publishing results of a study it conducted showing telephone counseling to be effective with Medicare beneficiaries. The North American Quitline Consortium is taking the lead in working with ATTUD and other organizations to advocate for coverage of telephone counseling. Phone f/up is considered by CMS as part of the care a qualified provider should provide and, as such, cannot be billed for. This extends to cessation via telephone – even a qualified, approved provider cannot bill for phone cessation services.
Q9. Is there any reimbursement for group counseling?
A: At this time, there is no reimbursement for group counseling. Although CMS found all forms of counseling to have significant effects on quitting, they found individual counseling to be the most effective and therefore decided not to reimburse for group (or telephone) counseling.
Q10. What is the fee schedule for this new benefit?
A: Currently, the national average rate for Moderate Counseling (3-10 minutes), CPT Code 99406, ranges from $10.91 to 17.78 depending upon your facility and geographic area. Intensive Counseling (over 10 minutes), the Code G0376, is $22.34 to $36.95. For rates specific to your area, contact your local Medicare carrier.
(To view a list of state carriers, go to www.pueblo.gsa.gov/cic_text/fed_prog/medicare/mhbkc05.htm.)
A: According to CMS, “smoking and tobacco use cessation counseling claims are to be submitted with the appropriate diagnosis code. Diagnosis codes should reflect the condition the patient has that is adversely affected by the use of tobacco or the condition the patient is being treated for with a therapeutic agent whose metabolism or dosing is affected by the use of tobacco”.
Q11. Is this new benefit cast in stone, or will there be changes?
A: It is unclear if the new Patient Protection and Affordable Health Care Act will affect reimbursement, and coding for tobacco dependence treatment. The Act does emphasize prevention and wellness and provides a new process by which medicare reimbursement will be managed, but there are not specific changes to support treatment for tobacco dependence except for provisions for pregnant women.
Q12.
What is ATTUD doing to advocate for this benefit and for reimbursement
of TTSs?
A: ATTUD will continue to advocate for this coverage in all appropriate forums. It is unlikely that CMS will change their definition of qualified providers to include TTS anytime soon. However, ATTUD will keep the issue alive, and will continue to emphasize the extensive infrastructure of well trained TTS who can provide this treatment in settings that include face-to-face, groups, and telephone counseling.
By continuing to address the issues of training standards for TTS and the related certification/program accreditation issues, ATTUD will be laying the foundation for a high level of competencies as a requirement for qualified providers
Q13. can I find more information about this benefit? REVISED 5/12/2010
A: To view a brochure produced by CMS primarily for Medicare recipients
about the smoking cessation counseling benefit, go to http://www.cms.gov/MLNProducts/downloads/smoking.pdfFor CMS information on the benefit and how to bill Medicare for delivering tobacco cessation counseling service please go to “The Guide to Medicare Preventive Services” Third edition published by CMS http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
Additional information is available through the Medicare Learning Network at
https://www.cms.gov/MLNMattersArticles/downloads/MM5878.pdf