CPT 99406, 99407, G0436, G0437 Smoking Cessation Counseling Codes.

Reviewed here are the smoking cessation counseling CPT® codes 99406, 99407, G0436 and G0437.  I am a hospitalist with over ten years of clinical experience.  I see hundreds of active smokers admitted to the hospital every year.  While being hospitalized can be traumatic, being a hospitalist provides me an opportunity to counsel my patients on their smoking and their smoking related illness.  Those efforts can now be submitted for payment.  Since late 2009, Medicare had paid for quit smoking counseling only if the patient had symptoms of tobacco related disease.  Physicians have collected payment using CPT® codes 99406, smoking and tobacco-use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes and CPT® 99407, smoking and tobacco-use cessation counseling visit, intensive,  greater than 10 minutes.  Please review the AMA's CPT 2014 Standard Edition (pictured below) as the definitive authority in CPT® coding.

That policy changed the following year.  Beginning on August 25th, 2010, CMS began paying for smoking cessation counseling even in patients without smoking related illness and introduced several new codes to account for that difference. See below for details.    Which patients qualify for payment of these face-to-face counseling services?  Under current law, the CMS manual says they   will pay for smoking cessation counseling for Medicare outpatient and hospitalized beneficiaries under the following circumstances for those
  1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
  2. Who are competent and alert at the time that counseling is provided; and,
  3. Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.
Since this new policy does not require an ICD diagnosis related illness, what code should be used for tobacco users without a tobacco related disease?  CMS gives guidance on that as well, instructing providers to use ICD-9 codes V15.82 (history of tobacco use) or 305.1 (non-dependent tobacco use disorder) in these circumstances.


Which codes should I use for my smoking cessation counseling for symptomatic and asymptomatic individuals?
  1. If the patient has symptoms related to their tobacco use, practitioners should continue to submit payment using the CPT® codes 99406 (intermediate) and 99407 (intensive) for their counseling efforts.
  2. For asymptomatic tobacco using individuals, two new codes G codes  have been introduced.  Starting in January 1st, 2011, the Accountable Care Act (ACA) provided for a waiver of Medicare coinsurance and Part B deductible requirements for these two G codes only.  
    • G0436 for greater than 3 minutes up to 10 minutes of counseling (intermediate)
    • G0437 for greater than 10 minutes of smoking cessation counseling (intensive)
The CMS rule says that Medicare will allow two individual tobacco cessation counseling attempts per year during which each attempt can include up to four intermediate or intensive sessions, for a maximum benefit of up to eight sessions per year.  How does Medicare define an attempt?
A cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. 
I could not find any information that defined a start and end time to a cessation counseling attempt.  My understanding is that any physician or other qualified practitioner can submit these codes.  As a hospitalist, I submit these codes all the time.  What better time to quit smoking than to be hospitalized in a campus wide no smoking environment filled with doctors and nurses? As an additional benefit, Medicare's prescription drug benefit plans should cover tobacco cessation pharmaceuticals.

 What documentation is required to receive payment for smoking cessation codes?  According to this February, 2012  CMS file:
Medical record documentation must show, for each Medicare beneficiary for whom a smoking and tobacco-use cessation counseling or counseling to prevent tobacco use claim is made, standard information along with sufficient beneficiary history to adequately demonstrate that Medicare coverage conditions were met.
Medicare will pay these smoking cessation counseling codes up to eight times a year  and they can be billed by any doctor or other qualified non-physician practitioner.  They are add on codes to other E&M services.   When smoking cessation counseling is billed in addition to other E/M charges on the same date, they should be reported using modifier 25 to indicate separately identifiable services.  I hope this helps you get paid for the services you are providing to your smoking beneficiaries.  Will non Medicare insurances pay for these codes?  They may.  Many private insurance carriers follow Medicare's payment guidelines, but you need to check with each company to verify their policy.


How many relative value units (RVUs) is tobacco-use cessation counseling worth (2014 values) and what is the reimbursement for these different levels of service?  The RVU dollar conversation ratio for 2014 is 35.8228.

CPT® 99406 and G0436:
  • work RVU 0.24
  • total RVU (facility) 0.34; about $11 in my geographic region.
  • total RVU (non-facility) 0.39; about $13 in my geographic region.
CPT® 99407 and G0437:
  • work RVU 0.50
  • total RVU (facility) 0.72 (0.74 for G0437); about $24 in my geographic region.
  • total RVU (non-facility) 0.77 (0.80 for G0437); about $26 in my geographic region. 
How often are the smoking cessation CPT® codes 99406 and 99407 billed to Medicare?  Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99406 and 99407 encounters and their dollar values billed to Part B Medicare.    Evaluation and management code 99406 was billed 289,298 times in 2011 with allowed charges of $3,837,187.29 and payments of $2,775,967.  Smoking cessation code  99407 was billed to Medicare Part B 62,243 times in 2011 with allowed charges of $1,660.343.80 dollars and payments of $1,236,043.43.


I recommend reviewing this Medicare Learning Network resource for more detailed information on smoking and tobacco-use cessation counseling coding.  In addition, make sure to check out all my other lectures on hospitalist coding.   Now, please enjoy the following story about my smoking cessation efforts in the hospital, hospitalist style!
She was  a 59 year old schizophrenic well known to Happy's service.  She'd been in and out of the hospital at least 6 times a year for the preceding five years, always for conditions related to smoking.  At 59 years old, she finds herself  in chronic hypercapnic and hypoxemic respiratory failure, requiring on average, 4 liters of oxygen support at all times. I have personally admitted her four times and each time I would discuss her smoking status and encourage her to quit.  Each time she would discuss her desire to quit but always failing to follow through.  She would be discharged, usually with the expectation that she would return in a month or two with the progressive revolving door of smoking related respiratory and cardiac failure. 
I would place her government funded smoking related medical expenses at well over one million dollars between her inpatient admissions, her outpatient follow ups and her chronic medication, oxygen and mobility devices.  One million dollars that could have compounded for generations to support the elderly in their final months of healthy living.  One million dollars that could have funded ten times as many people in the final stages of their advanced end of life aging process. 
People who smoke die young.  But they still become net consumers  as opposed to producers. If they don't quit smoking for good, they become disabled and live that way for years upon years upon years before succombing to their premature death..  They spend vast amounts of economic resources that could have compounded for generations before their body was meant to fail. 
The last time I saw her was an evaluation for admission in the emergency room for dyspnea.  Her baseline carbon dioxide was normal, for her.  Her chronic oxygen needs were normal, for her.  Her complaints were undifferentiated from her chronic complaints except this time she wasn't a smoker.  And she told me I was her inspiration.  She told me my lectures to her inspired her desire to give it up.  For over four decades she slaved away at the grips of a nicotine addiction. 
Whenever you feel like your words are just that, it's nice to know that some folks out there are actually listening.  I may have added a good three or four years to her life to spend with  her children and grandchildren.  I may have prevented her from getting admitted to the hospital six times a year.  Perhaps now it will be only two or three.  Perhaps someday, instead of getting paid $12 or $25 for my tobacco counseling under fee for service, I will get a gainsharing reward for keeping her out of the hospital.  I sent her home that day.  Home because she wasn't having a COPD exacerbation.  Home because she was stable, for her.  Home to be with her family and away from the expensive and dangerous hospital environment.


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

Click image for high definition view

Print Friendly and PDF