What to Look for When Auditing Smoking Cessation Services What to Look for When Auditing Smoking Cessation Services

What to Look for When Auditing Smoking Cessation Services

Scott Kraft, CPC, CPMA

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

What to Look for When Auditing Smoking Cessation Services
Lots of physician practices overlook the opportunity to bill for furnishing smoking cessation services to patients. These services are unlikely to create a financial windfall, but with payments that range from $15-$30 per encounter, the payments can add up. Not to mention that most physicians are already doing the work of trying to help smokers quit as part of just about any primary care service for those who smoke.
As an auditor, however, when practices do embrace billing for smoking cessation, you will often see common errors that can result in either a flat-out denial for not meeting the documentation requirements, or leave it open to being challenged by an insurance company auditor down the road – a process which isn’t worth the hassle of fighting over for the amount that smoking cessation services pay.
Fortunately, there are simple steps providers can take to meet the relatively modest requirements to bill for these services.
First, let’s look at the CPT codes. Providers bill 99406 for a smoking cessation service lasting between 3 and 10 minutes, and 99407 for services that are more than 10 minutes long. Using Medicare as a benchmark, the pay for 99406 is just under $16 and the pay for 99407 is just under $31.
These services can be billed during the same encounter as an evaluation and management (E/M) service and will typically not require a modifier.
When you’re auditing these services, be mindful of these rules:
  • Time must be documented: For 99406, a minimum of three minutes must be documented as time spent by the provider for the service to be billable. Time rules aren’t halved for these codes as they are for some others. Any amount of time under 3 minutes is not billable. Time between 3-10 minutes is covered by 99406 and time over 10 minutes is 99407. Time cannot be combined to use both codes on the same date.
  • Frequency limits may apply:For example, Medicare covers two separate attempts to quit smoking per year, and each attempt may consist of up to four cessation counseling encounters. Consequently, the service is not payable for more than eight visits per year.
  • Patient willingness to attempt to quit:The service is smoking cessation counseling and for it to be billable, the patient must express some willingness to attempt to quit, even if ultimately unsuccessful. Patients who have no interest in quitting smoking under any circumstance are not good candidates for the service.
  • Documentation components:While there is no set rule for each aspect of documentation beyond the counseling time, typical documentation includes risks of continuing to smoke, benefits of not smoking and cessation strategies, including such things as cessation aides and methods, setting a date to quit, risks of returning to smoking and potential prescription drug management. All of these things don’t need to be documented, but documentation such as “discussed smoking cessation for four minutes,” is insufficient to bill these services.
  • No “double dipping”:If you fail to document smoking cessation counseling time, or opt not to bill 99406-99407, medical decision making related to smoking cessation can be considered part of the E/M service. If you are billing for smoking cessation counseling, the patient’s smoking cessation should not also be considered to be part of the medical decision making of the problem focused E/M service.
  • Diagnosis codes:The most common primary diagnosis code for smoking cessation is F17.200 for nicotine dependence, unspecified, uncomplicated, but look to codes between F17.200 and F17.291 for the most appropriate choice. Chronic diseases that are negatively impacted by smoking or tobacco use can be coded as secondary diagnoses.


This Week’s Audit Tip Written By:
Scott Kraft, CPC, CPMA
Scott is a Senior Compliance Consultant with our parent organization, DoctorsManagement

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email info@drsmgmt.com.
  2. Read more: What can you expect from a coding and compliance review?
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