Smoking Cessation
Effective Date: November 15, 2021
Purpose:
This reimbursement policy provides guidelines on how to bill for smoking cessation when billed with certain diagnosis codes or Evaluation and Management services provided on the same date of service.
Scope:
Products included:
- NJ FamilyCare/Medicaid
Definitions:
- 99202-99397 and 99420-99499: Evaluation and Management Services
- 99406 or 99407: Smoking and tobacco cessation counseling visit
Policy:
Horizon NJ Health will consider for reimbursement smoking and tobacco cessation counseling visits (99406 or 99407) for asymptomatic patients only when billed with an approved diagnosis of nicotine dependence, toxic effect of tobacco and nicotine, or personal history of tobacco use.
Approved Diagnosis Codes:
- Nicotine dependence (F17.21-F17.299)
- Personal history of nicotine dependence (Z87.891)
- Initial encounter, toxic effect of tobacco and nicotine (T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A)
Horizon NJ Health will consider for reimbursement Evaluation and management (E&M) services provided on the same day as smoking and tobacco-use cessation counseling services (99406 or 99407) only when medically necessary, as indicated by appending modifier -25. Also, in keeping with CMS guidelines, Horizon NJ Health will limit smoking and tobacco-use cessation counseling (99406 or 99407) in any combination to eight units within a one-year period.
Procedure:
Horizon NJ Health will not consider for reimbursement CPT codes 99406 or 99407 (Smoking and tobacco cessation counseling visit) when billed without an approved diagnosis of nicotine dependence, toxic effect of tobacco and nicotine, or personal history of tobacco use.
Horizon NJ Health will not consider for reimbursement CPT codes 99202-99397 or 99420-99499 (E&M service) when billed with 99406 or 99407 (Smoking and tobacco cessation counseling visit) on the same date of service and modifier -25 is not appended.
Horizon NJ Health will not consider for reimbursement CPT codes 99406 or 99407 (Smoking and tobacco cessation counseling visit) when billed in any combination of more than eight units in a one-year period by the same or different provider.
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations;
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
References:
American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services
CMS "National Coverage Determination (NCD) for Counseling to Prevent Tobacco Use (210.4.1)"