ATTUD the Association for the Treatment of Tobacco Use and Dependency  
 

Medicare Frequently Asked Questions
New Medicare Benefit For Tobacco Counseling
(Reviewed 6/2008)

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 at: attud@umdnj.org. The membership will respond.

  1. What is the Medicare benefit for tobacco counseling?
  2. Does this mean any smoker or tobacco user 65 or older can receive treatment for tobacco dependence?
  3. Which providers are authorized by Medicare to receive payment for services?
  4. What is the billing code?
  5. Can non-authorized Medicare providers who are providing tobacco dependence counseling on an OUTPATIENT basis be reimbursed incident to a physician's professional services?
  6. Can non-authorized Medicare providers who are providing tobacco dependence counseling on an INPATIENT basis be reimbursed incident to a physician's professional services?
  7. Is there any allowance for inpatient tobacco counseling to be covered by auxiliary personnel?
  8. Is there any reimbursement for telephone counseling?
  9. Is there any reimbursement for group counseling?
  10. What is the fee schedule for this new benefit?
  11. What forms and codes do you need to use to bill for this service?
  12. Is this new benefit cast in stone, or will there be changes?
  13. What is ATTUD doing to advocate for this benefit and for reimbursement of TTSs?
  14. 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 covers 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.

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.) We are not sure yet if these non-physician providers may in fact bill for tobacco counseling under their own name, but it appears so based on this excerpt from the Medicare Benefit Policy Manual.

Q4. What is the billing code?

A: G0376 for moderate counseling; Short descriptor: Smoke/Tobacco counseling 3-10.
G0376 for intensive counseling; 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: We have received multiple and conflicting responses to this question and the answer appears to vary depending upon individual state and local carriers. The answer appears to be “no” in the northeast, but “yes” in other states. ATTUD is continuing to seek clarification on this issue, so please continue to check this section for updates.

We are investigating whether a non-authorized Medicare clinician who provides counseling services “incident to” the physician and who has been deemed by the physician and/or clinic to be the appropriate person to provide this service can bill under the physician. “Incident to a physician’s professional services means that the services are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.” (Medicare Benefit Policy Manual, Chapter 15, Section 60.1A) This coverage of service incident to a physician’s services by auxiliary personnel “is limited to situations in which there is direct physician supervision”. However, “direct supervision” in the office setting does not mean that the physician must be present in the same room with his or her auxiliary staff, but that he/she must be on the premises and able to “provide assistance and direction” while the staff member is performing the service. (Section 60.1B) Within a clinic setting, where there may be a number of physicians working, the physician who ordered the service does not need to be the physician who supervises the service, so that “service performed by auxiliary personnel and other aides are covered even though they are performed in another department of the clinic”. (Section 60.3). Only the physician or other CMS approved provider can bill.

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

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), Code G0375, is $12.89, and the national average rate for Intensive Counseling (over 10 minutes), Code G0376, is $25.39. This rate varies according to geographic location. 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.) CMS is expected to post these rates and ask for public comment. Often rates are adjusted upwards if there is evidence to support a higher rate (e.g. significant training requirements in order to provide the service)

Q11. What forms and codes do you need to use to bill for this service?

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”. (MedlearnMatters No MM3834)

Q12. Is this new benefit cast in stone, or will there be changes?

A: CMS has asked the Agency for Healthcare Research and Quality (AHRQ) to convene a stake-holders meeting in November 2005 to discuss training and credentialing issues related to this benefit. ATTUD will be at the table representing our membership and presenting information to help CMS define  qualified providers . Denise Jolicoeur (ATTUD President) and Ken Wassum (ATTUD President Elect) will lead the writing of two ATTUD sponsored white papers: 1) a report of the current landscape of tobacco treatment training and certification programs, and 2) establishing competencies for tobacco treatment providers. In addition ATTUD member Lowell Dale, MD will author the third white paper reviewing the literature related to effectiveness of professional training programs. Representatives from a number of organizations will be invited. These include CDC, SRNT, AMA, NAQC (North American Quitline Consortium, telephonic cessation vendor(s), as well as representatives from the American Nurses Association, Respiratory Therapists, Social Workers, and others. It is hoped that as a result of this stakeholders meeting critical training, certification and reimbursement issues will be raised and acted upon.

Q13. 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, by participating in forums like the stakeholders meeting to be convened by AHRQ, 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.

Q14. Where can I find more information about this benefit? REVISED 4/24/08