Saturday, July 21, 2012

CPT CODE G0436, G0437, 99406, 99407

cpt code and description

99406
- Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes - Avreage fee amount- $12 - $18


99407 - Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes -Avreage fee amount- $25 - $30

Update from Medicare

Note: HCPCS code G0436 and G0437 will be discontinued effective 10/1/2016. CPT codes 99406 and 99407 are the remaining codes for tobacco cessation counseling. The beneficiary copayment is waived for CPT codes 99406 and 99407.

Policy:  Effective for claims with dates of service on and after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:

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.

These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations. The diagnosis codes that should be reported for these individuals are ICD-9 codes 305.1, nondependent tobacco use disorder, or V15.82, history of tobacco use.


Tobacco Cessation Counseling - G0436/G0437 and 99406/99407

Medicare Part B already covers cessation counseling for individuals who:


1. Use tobacco and have been diagnosed with a recognized tobacco-related disease

2. Use tobacco and exhibit symptoms consistent with a tobacco-related disease


In November 2009, based upon authority to cover ‘additional preventive services’ for Medicare beneficiaries if certain statutory requirements are met, the CMS initiated a new national coverage analysis. This analysis was to evaluate whether the existing evidence on counseling to prevent tobacco use is sufficient to extend national coverage for cessation counseling to those individuals who use tobacco (but do not have signs or symptoms of tobacco-related disease).

One of these statutory requirements is that the service be categorized as a grade A (strongly recommends) or grade B (recommends) rating by the US Preventive Services Task Force (USPSTF).

CR 7133 instructs that, effective for claims with dates of service on and after August 25, 2010, CMS will cover counseling to prevent tobacco use for outpatient and hospitalized Medicare beneficiaries:


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

3. Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner



These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations.

The diagnosis codes that should be reported for these individuals are:

  • ICD-9 code 305.1 (non-dependent tobacco use disorder)
  •  ICD-9 code V15.82 (history of tobacco use)

The temporary HCPCS G codes G0375 and G0376, which are currently used to bill for Smoking and Tobacco Use Cessation Counseling services, are effective only through December
31, 2007.

They are being replaced by two new CPT codes (99406 - Smoking and tobaccouse cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes; and 99407 - Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes). These new CPT codes, which are included in the 2008 Medicare Physician Fee Database (MPFSDB), become effective for  claims with dates of service January 1, 2008 and later.

FIs, carriers, and A/B MACs will pay for counseling services billed with HCPCS codes G0375 and G0376 for dates of service performed on and after March 22, 2005 through Dec. 31, 2007 and with CPT codes 99406 and 99407 for dates of service on or after January 1, 2008. 

Reimbursement Guidelines

Optum will align reimbursement with Medicare including up to 2 attempts of up to 4 sessions each for a total of up to 8 face-toface visits during a 12-month period for individuals who use tobacco – regardless of whether there are signs or symptoms of tobacco-related disease. These visits must be provided by a qualified health care provider.

CPT codes for tobacco cessation counseling for symptomatic individuals are:

• 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

• 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

Peach State Health Plan will provide reimbursement for tobacco cessation therapy services CPT 99406 and CPT 99407. Tobacco cessation therapy services may be billed in conjunction with the appropriate evaluation and management office visit code when medically necessary.

Supporting documentation: Proper documentation for codes 99406 and 99407 include the total time spent and what was discussed, including cessation techniques, resources and follow-up. Be sure to have distinct documentation to support this service if reported in conjunction with another E/M service. 

The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use for dates of service on or after January 1, 2011. These are in addition to the two CPT Codes 99406 and 99407 that currently are used for tobacco cessation counseling for symptomatic iindividuals. Medicare will waive the deductible and coinsurance/copayment for counseling and billing with these two new G codes on or after January 1, 2011.

The new G codes for use on claims with dates of service on or after January 1, 2011 are:

  •  G0436: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than three minutes, up to 10 minutes; Short Descriptor: Tobacco-use counsel three to 10 minutes

  •  G0437: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes; Short Descriptor: Tobacco-use counsel >10 minutes.
Coverage Limitation

CWF shall deny counseling to prevent tobacco use services (HCPCS G0436, G0437, 99406, 99407) that exceed a combined total of 8 sessions within a 12-month period.

NOTE: In calculating a 12-month period, 11 months must pass following the month in which the 1st Medicare covered cessation counseling session was performed.

Contractors shall allow payment for a medically necessary E/M service on the same day as the smoking and tobacco-use cessation counseling service when it is clinically appropriate. Physicians and qualified non-physician practitioners shall use an appropriate HCPCS code, such as HCPCS 99201– 99215, to report an E/M service with modifier 25 to indicate that the E/M service is a separately identifiable service from G0375 or G0376.


Contractors shall only pay for 8 Smoking and Tobacco-Use Cessation Counseling sessions in a 12-month period. The beneficiary may receive another 8 sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered cessation session was performed. To start the count for the second or subsequent 12-month period, begin with the month after the month in which the first Medicare covered cessation session was performed and count until 11 full months have elapsed.


Claims for smoking and tobacco use cessation counseling services shall be submitted with an appropriate diagnosis code. Diagnosis codes should reflect: the condition the patient has that is adversely affected by tobacco use or the condition the patient is being treated for with a therapeutic agent whose metabolism or dosing is affected by tobacco use.

NOTE: This decision does not modify existing coverage for minimal cessation counseling (defined as 3 minutes or less in duration) which is already considered to be covered as part of each Evaluation and Management (E/M) visit and is not separately billable.


Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes


When denying claims for counseling to prevent tobacco use services submitted without diagnosis codes 305.1 or V15.82, contractors shall use the following messages:

MSN 15.4: The information provided does not support the need for this service or item.

MSN Spanish Version: La información proporcionada no confirma la necesidad para este servicio o artículo

 RARC M64 - Missing/incomplete/invalid other diagnosis

 CARC 167 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

Contractors shall use Group Code CO, assigning financial liability to the provider, if a claim is received with no signed ABN on file.

When denying claims for counseling to prevent tobacco use services and smoking and tobaccouse cessation counseling services that exceed a combined total of 8 sessions within a 12-month period (G0436, G0437, 99406, 99407), contractors shall use the following messages:

MSN 20.5: “These services cannot be paid because your benefits are exhausted at this time.”

MSN Spanish Version: “Estos servicios no pueden ser pagados porque sus beneficios se han agotado.”

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N362: “The number of days or units of service exceeds our acceptable maximum.”

Contractors shall use Group Code PR, assigning financial liability to the beneficiary, if a claim is received with a signed ABN on file.

Contractors shall use Group Code CO, assigning financial liability to the provider, if a claim is received with no signed ABN on file.

 Post-Payment Review for Smoking and Tobacco-Use Cessation Counseling Services

As with any claim, Medicare may decide to conduct post-payment reviews to determine that the services provided are consistent with coverage instructions. Providers must keep patient record information on file for each Medicare patient for whom a Smoking and Tobacco-Use Cessation Counseling claim is made. These medical records can be used in any post-payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.

Common Working File (CWF) Inquiry

The Common Working File (CWF) maintains the number of smoking and tobacco-use cessation counseling sessions rendered to a beneficiary. By entering the beneficiary’s health insurance claim number (HICN), providers have the capability to view the number of sessions a beneficiary has received for this service via inquiry through CWF.



 Provider Access to Smoking and Tobacco-Use Cessation Counseling Services Eligibility Data

Providers may access coverage period remaining smoking and tobacco-use cessation counseling sessions and a next eligible date, when there are no remaining sessions, through the 270/271 eligibility inquiry and response transaction.

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