CMS expands tobacco cessation counseling, focuses on audits

Developments at the Centers for Medicare and Medicaid Services will benefit those who want to quit smoking, but will also increase audit scrutiny over physician and facility claims.

Two new developments at the Centers for Medicare and Medicaid Services will, in turn, benefit patients who want to stop smoking and increase audit scrutiny over physicians' claims, in addition to facility claims.

Smoking cessation expanded


Medicare's expanded coverage of tobacco cessation counseling, as an evidence-based preventive service under the Medicare Improvements for Patients and Providers Act (MIPPA), begins Jan. 1, 2011, and removes a previous barrier to treatment for all tobacco users covered by Medicare. Previously, the counseling benefit was available only to those who had a tobacco-related illness or symptoms, or whose metabolism or medication was adversely affected by tobacco use.

Tobacco use is the leading cause of preventable illness and death in the United States and is a major contributor to the nation's increasing medical costs. The Centers for Disease Control and Prevention estimates that one-fifth of deaths in the U.S. each year are attributable to tobacco use. The CDC also estimates that, between 1995 and 2015, tobacco-related diseases will cost the Medicare program $800 billion.

Now, any tobacco users with Medicare coverage will be able to receive tobacco cessation counseling from a qualified physician (or from any other Medicare-recognized practitioner who can work with them to help them stop using tobacco). The new benefit will cover up to two individual tobacco cessation counseling attempts per year. Each attempt may include up to four sessions, resulting in an annual benefit that covers up to eight sessions per beneficiary.

The coverage will apply to services under Parts A and B of Medicare, and the tobacco cessation benefit under the Medicare Prescription Drug Program (Part D) will continue to be available. CMS will offer the tobacco cessation counseling preventive service without deductible or coinsurance payments from the beneficiaries, because the Patient Protection and Affordable Care Act provides for waived deductibles and coinsurance for certain preventive services.

CMS has not yet announced coding guidelines for the expanded benefit, but ACP expects that the coding will continue to use the existing CPT codes.

  • 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.

Counseling services less than three minutes in length are not separately billable; they are included in the evaluation and management service for the visit.

The reimbursement to physician practices (unadjusted for geographic region) for the two services is currently $13.35 and $25.62, respectively. At this time, the 2011 reimbursement can only be estimated, but if the Medicare fee schedule conversion factor remains at $36.08 and Medicare conducts its scheduled update of the practice expense of the services, the payments will be approximately $14.00 and $29.00 in 2011. More accurate payment figures will be available after publication of the Medicare physician fee schedule final rule, at the end of 2010.

ACP is a long-time advocate of efforts to reduce tobacco use in the United States and a strong supporter of physician engagement with patients regarding their tobacco use. The College supports broad Medicare tobacco cessation coverage consistent with the evidence. It also has urged private payers to cover tobacco cessation counseling as a standard benefit.

The ACP position is summed up in a 2010 College statement that “Public and private insurers, as well as state, community, and employer-based entities, should provide all effective comprehensive tobacco cessation and treatment benefits, including counseling and medication, to all qualifying individuals. Physicians should help their patients quit.”

Audits to focus on claims

Recent decisions by CMS regarding the Recovery Audit Contractors (RAC) program have put physicians' claims back in the auditors' sights.

CMS set up the program to detect and resolve past payment errors in Medicare fee-for-service claims. Since a demonstration project ended in 2008, the RACs have focused mostly on hospital or other facility claims rather than on physicians' claims.

The RACs have also added the Medically Unlikely Edits (MUEs) to their arsenal of audit issues. MUEs were previously discussed in the September 2010 ACP Internist.

Earlier this year, CMS announced that the RACs could now audit for these types of errors that could affect physicians' Part B claims:

  • multiple billings for procedures that would happen no more than once in a lifetime,
  • newborn pediatric CPT codes that are billed for patients who exceed the codes' age limit,
  • facility versus non-facility professional component payment errors,
  • excessive number of blood-transfusion units billed per patient per date of service,
  • excessive number of bronchoscopy services billed per patient per date of service,
  • excessive number of intravenous hydration units billed per patient per date of service,
  • professional and technical components paid separately when a global payment should have been applied,
  • separately paid hospice-related services that should have been included in payment to the hospice,
  • skilled nursing facility consolidated billing errors and
  • services billed for dates of service beyond the patient's date of death.

Each contractor has some degree of discretion to decide which issues to pursue, so you may find that your region's contractor may not have all the above-listed issues on its approved issues list. To determine which issues are currently under review by your region's contractor, please consult the respective websites:

ACP will continue to track the activities of the RACs and other claims audit programs, in addition to reviewing proposed MUEs. ACP Internist published a previous article on the RAC program, including a list of the states within each jurisdiction, in its June 2009 issue.