American College of Physicians: Internal Medicine — Doctors for Adults ®


Medicare ushers in new smoking cessation coverage

Tobacco use remains the No.1 cause of preventable death in this country

From the May ACP Observer, copyright 2005 by the American College of Physicians.

By Kerry Hunt

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) instituted a change that promises to help many Medicare patients: In March 2005, the agency began covering cessation counseling for smoking and other tobacco use for eligible beneficiaries.

In explaining why it chose to begin coverage, the CMS quoted estimates from the Centers for Disease Control and Prevention that more than 9% of Americans age 65 and older smoke and that smoking-related illnesses account for as much as 10% of total Medicare costs. Tobacco use remains the No. 1 cause of preventable death in this country.

Q: Which beneficiaries are eligible for cessation counseling?

A: Instead of paying for cessation counseling for all Medicare patients who smoke or use tobacco, the CMS will cover counseling only for patients diagnosed with an illness or an adverse health effect related to tobacco or who are taking medications that are complicated by tobacco use.

In its coverage announcement, the CMS broadly defined "adverse health effects" to include a wide array of diagnoses, ranging from heart disease and cancers to cough. The 2004 U.S. Surgeon General's Report provides a comprehensive list of tobacco related-illnesses, any of which would make beneficiaries eligible for this new coverage.

Q: How many cessation counseling sessions will Medicare cover?

A: Medicare will cover two cessation attempts per 12-month period for each eligible beneficiary. Each attempt may include up to four face-to-face counseling sessions, for a maximum of eight covered counseling sessions per 12-month period.

The CMS has established two different billing levels for face-to-face counseling sessions: intermediate and intensive. Counseling sessions that last between three and 10 minutes should be billed as intermediate, while those lasting more than 10 are considered intensive. The physician, in consultation with the patient, will decide whether intermediate or intensive counseling sessions are needed.

Q: How does Medicare define cessation counseling?

A: In its coverage announcement, the CMS claims effective counseling includes three components: practical counseling on problem-solving and skills training; intra-treatment social support, which includes encouragement to quit; and extra-treatment social support, which includes referral to support groups.

Q: What if I counsel an eligible beneficiary for less than three minutes?

A: Payment for any cessation counseling that takes less than three minutes is considered to be already included in the evaluation and management service. As a "bundled" service, it cannot be billed separately.

Q: Will Medicare cover cessation counseling for hospitalized patients?

A: Yes, the CMS will cover cessation counseling for eligible beneficiaries in both inpatient and outpatient settings. However, the CMS stated in its coverage announcement that "[i]npatient hospital stays with the principal diagnosis of 305.1, Tobacco Use Disorder, are not reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, we will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient's hospital stay."

Q: Who can provide cessation counseling?

A: Medicare will reimburse qualified physicians and other Medicare-recognized clinicians for cessation counseling. While there is currently no nationally accepted definition of the term "qualified," the CMS has said that efforts are under way to develop such a definition. The agency may adopt and implement certification requirements in the future.

Q: What billing codes are associated with the new benefit?

A: The CMS has created Healthcare Common Procedure Coding System (HCPCS) codes you can use to bill the counseling sessions, effective for services performed on or after March 22, 2005. The following are new HCPCS codes:

G0375: Smoking and tobacco use cessation counseling visit; intermediate; greater than 3 minutes up to 10 minutes

G0376: Smoking and tobacco use cessation counseling visit; intensive; greater than 10 minutes

During a cessation-counseling pilot project conducted between November 2002 and December 2004, Medicare paid an average of $32 for each intermediate counseling session.

Q: Will Medicare cover prescription smoking cessation medications?

A: Yes. Beginning Jan. 1, 2006, prescription smoking-cessation medications will be covered for eligible Medicare beneficiaries in accordance with the Medicare prescription drug benefit. A complete list of covered cessation medications will be issued later this year when details of the prescription drug benefit are finalized.

More details about CMS' cessation coverage are online.

Kerry Hunt is a Senior Analyst in ACP's Washington office.


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