This post is part of an occasional series called Ask the Experts in which Tobacco Treatment Specialists from the Duke-UNC TTS Training Program answer questions from patients and other healthcare providers commonly encountered in clinical practice. Do you have a question of your own? Submit your question here!
Reimbursement for tobacco treatment services can be complicated. We sat down with Jillian Dirkes, Program Manager of the Duke Smoking Cessation Program and co-founder of the Duke-UNC Tobacco Treatment Specialist Training Program, to ask her about her experience with billing for tobacco treatment services.
What is the best way to bill for tobacco treatment services?
There really is no one way to approach this question. Billing and being reimbursed for services starts with answering these three questions:
What insurance are you trying to bill? The first thing to evaluate is what insurance company covers the person you are trying to see. Every insurance has different rules for settings and providers they reimburse.
Where will you see this person? Defining your setting – medical outpatient, skilled nursing facility, in the individual’s home, behavioral health group, pharmacy – will guide you to look at the right rules and set of codes.
What type of provider or clinician will see this person? Different provider types and specialties use different codes. As an example, physicians and other medical professionals use codes called Current Procedural Terminology, which are billed to medical payors, while dentists use Current Dental Terminology, which are billed to dental payors. Some specialties, like psychiatry, may also have specialized codes.
Once you know the answer to these three questions, you can start to hone in on the billing strategy that makes sense for your population, your setting, and your professional type.
I am certified as a tobacco treatment specialist through NAADAC or the American Heart Association. Is that enough to start billing?
Unfortunately, this is not usually enough to bill as an independent provider.
However, some insurance types may cover incident-to billing in the outpatient medical setting. This means a non-physician provider bills for the services as if they are the physician. To learn more about the requirements for billing incident-to, consult with the payor directly.
Example: A patient with Medicare talks with their primary care provider about quitting smoking at their annual physical in July. The primary care provider writes a prescription for varenicline and recommends the patient continue regular check-ins with the tobacco treatment specialist (TTS) who is employed by the same entity as the physician. The patient comes back every two weeks for counseling with the TTS for 30 minutes of counseling when the physician is in the building. The TTS bills CPT code 99407, under the supervising physician’s provider ID, and updates the physician regularly on the plan of care.
What if I have a different license type and already bill for services?
If you have a different license type, you can often use the tobacco cessation codes or the kinds of codes you are already using or add on a code to capture the extra time spent offering counseling.
CPT codes 99406 (3-10 minutes) and 99407 (greater than 10 minutes) are used to bill for time spent in the outpatient setting doing direct counseling with a person on tobacco cessation. You should document what you assessed, the counseling provided, and include a visit diagnosis that corresponds with tobacco use. Use a -25 modifier when providing this counseling on the same day as a visit for other separately identifiable Evaluation & Management (E/M) services.
Example: You are a nurse practitioner seeing a patient in the outpatient setting for COPD and additionally did 10 minutes of tobacco cessation counseling. In this instance, you would bill an E/M code using medical decision-making (99212-99215) and add on 99407 with a -25 modifier. You would list the visit diagnosis as COPD and F17.200 (ICD-10 code for nicotine dependence). Alternatively, if the primary focus was tobacco cessation, you could bill the E/M code alone using time-based billing and omit the 99407, listing visit diagnosis as F17.2XX.
How can I learn more?
The rules around billing are complex, dictated by location, and frequently changing. I have learned most of this information by accessing the following resources:
Consulting with my institution’s coding and compliance teams to review documentation and billing practices
Staying connected with my state’s tobacco prevention and control branch for updates on Medicaid and other state-level changes
Connecting with other tobacco treatment professionals at other institutions.
Want to learn more about billing and coding for tobacco treatment services? Register for our upcoming Comprehensive TTS Training Program on July 15-23, 2024. Learn more at www.dukeunctts.com/programs.