Documentation Tips

Documentation Tips: Smoking Cessation Counseling

Documentation Tips: Smoking Cessation Counseling

In the event that time is spent counseling a patient regarding smoking cessation, this may be a separately reportable service in addition to the E/M level. The associated time-based codes are as follows:

99406 – Smoking and tobacco use cessation counseling, 3 to 10 minutes

99407 – Smoking and tobacco use cessation counseling, > 10 minutes.

These codes are used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury.  They involve specific validated interventions and are time based. The intermediate service requires 3-10 minutes of counseling and the intensive service requires greater than 10 minutes. New rules allow smoking cessation to be reported for all patients regardless of any history of smoking.

“Counseled pt re smoking cessation for 5 min, Rx for patch provided, pt receptive.”

NOTE: Counseling may be provided by physician or NPP.

These codes are reimbursable by Medicare.  Reimbursement by other payers may vary.

In order for these codes to be assigned and billed, the chart documentation should include the following:

  1. Documentation that patient is alert and competent.
  2. Documentation of cessation discussion, including:
    • time spent,
    • treatment plan recommended, and
    • patient response.

Example of Acceptable Documentation for #4

“Counseled pt re smoking cessation for 5 min, Rx for patch provided, pt receptive.”

NOTE: Counseling may be provided by physician or NPP.

These codes are reimbursable by Medicare.  Reimbursement by other payers may vary.

In the event that chart documentation reflects smoking cessation counseling occurred but the time requirement is not documented, the coder will assign a deficiency code 8185 will be assigned to identify a potential loss in reimbursement.  If time is documented but less than the minimum time requirement, this will not be assigned as a deficiency since it is not a separately billable service.

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