New Beginning - New Year: Documentation & Coding for Smoking Cessation

Welcome to 2014 - Here's my contribution to helping make the lives our our pregnant patients (and their babies) a bit better.... It is a known fact that smoking during pregnancy has an adverse effect upon fetal health and growth during the antepartum period. As OB/GYN practices, we have the unique opportunity to counsel and provide support for the patient to quit smoking during the pregnancy. If we are successful, both mom and baby benefit. According to ACOG “Approximately 50–60% of women who quit smoking during pregnancy return to smoking within 1 year postpartum, putting at risk their health, that of their infants, and the outcomes of future pregnancies. Determining a woman's intention to return to smoking during the third trimester has proved useful at targeting smoking relapse interventions. Most pregnant former smokers indicate that they do not intend to smoke. To strengthen their resolve for continued smoking abstinence, a review of tobacco use prevention strategies and identification of social support systems to remain smoke free in the third trimester and postpartum is encouraged).” In addition to ACOG, CMS and Medicaid bought into paying for care support for patients of all ages, and have implemented payment and RVU’s associated with smoking cessation counseling. (In the CMS manual (http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2058CP.pdf The CMS Transmittal policy states: 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, non-dependent tobacco use disorder, or V15.82, history of tobacco use. The CMS will allow two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate OR intensive sessions, with a total benefit covering up to 8 sessions per year per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than 3 minutes but less than 10 minutes), or intensive (more than 10 minutes) cessation counseling sessions for each attempt. The reality is not many of our OB patients have Medicare part B or part A benefits, but many private insurance carriers have also supported the health benefit of smoking cessation and have begun to pay for these services as a part of a patient “wellness” program. Of course, there are limits and documentation requirements for these codes. The easiest way to document smoking cessation counseling is with a template and following these specific elements. We have included a template that you can use and modify for your particular practice. (word and pdf format are available)  Face-to-face counseling that involves specific validated interventions. o This can include the problem/diagnosis related to smoking and tobacco abuse o Any medications/drugs the patient takes that are affected by tobacco use/abuse  Assessment of readiness for change  Barriers to change  Advising behavior changes (with specific actions)  Motivational counseling to include an outline detailing the discussion with the patient (including advice regarding how to quit, how to manage side effects, referral to a consultant MD for long-term counseling and monitoring  Arranging and/or providing services for continuation and follow up.  A record of time spent with the patient exclusive to counseling. In the caveat of taking the time to pursue tobacco cessation counseling, your patient and the developing fetus are the ones that truly benefit. As the provider of the service, you will be able to add a small additional chargeable service to your practice revenue. The 2013 RVU values and reimbursement show the 99406/G0436, (3-10 minute session) reimburses aprox. $13.00 and the non-facility is aprox 0.41 RVU’s. The 99407/G0437 (greater than 10 minute session) reimburses aprox. $25.00 and the RVU’s are aprox. 0.79 for non-facility. To find what your carrier pays in your local area you can find it on the Medicare site at this web address: http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx Most private insurance carriers prefer to be billed with the CPT codes of 99406/99407, and the Medicare/Medicaid/Tricare Government sponsored payers prefer to be billed with the HCPCS codes of G0436/G0437. The diagnosis is also a key component for reimbursement with pregnant patients. Currently, ICD-9 codes, 305.1 (non-dependent tobacco use disorder), 649.03 (Tobacco use disorder complicating pregnancy, childbirth, or the puerperium), or V15.82 (history of tobacco use) should be used on your claim for reimbursement. In the light of full disclosure be sure to inform your patient, they are consenting to, and participating in a smoking cessation counseling session. They also need to know they have the option to receive the counseling, or decline it. In addition, the patient’s insurance carrier may or may not pay for these services. If the carrier does not pay, or the patient is unsure if their policy pays for this service, the patient would then be responsible for the charges. If you, or the patient, are unsure if the patients’ insurance carrier pays for smoking cessation counseling services, have the patient sign an Advance Beneficiary Notice prior to providing the service. Patient Readiness for Change: Another issue that providers should be aware of is being able to identify the readiness or “stages of change” that help identify if the pregnant patient is truly willing to make this type of change during their antepartum care. These stages are identified as 1.Pre-Contemplative Stage: Not ready to quit 2.Contemplative Stage: Thinking about quitting; Aware of need to quit smoking 3.Action: Ready to quit; Agreeable to counseling classes or other intervention 4.Maintenance: Has quit; Reinforce need to not smoke 5.Relapse: Reinforce that patient may go through stages of change several times before complete cessation occurs Physician/Staff & Education Resources: If you would like to have more information I have included a list of educational resources for providing smoking cessation counseling and additional services that are free or of very low cost for your practice. ■U.S. Department of Health and Human Services Guideline: Quick Reference Guide for Clinicians, Treating Tobacco Use and Dependence. Available from Agency for HealthcareResearch and Quality (AHRQ) 1-800-358-9295. ■Health Care Excel, Incorporated (private, not for profit organization) Education Video (developed in conjunction with Indiana University School of Medicine); ReversingTrends: Smoking Cessation Techniques for the Health Care Professional. This video is available for CME credit. Available from Health Care Excel at eswinehart@hace.org ■Fiore, Michael C., MD, MPH. A Clinical Practice Guideline for treating Tobacco-use and Dependence: A U.S. Public Health Service Report.JAMA, June 28, 2000: 3244-3254. ■Best Practices for Comprehensive Tobacco Control Programs, CDC. Ordering informationand annotation available at http://www.cdc.gov/tobacco/pubs2.htm ■National Guidelines Clearinghouse http://www.ngc.gov/FRAMESETS/SEARCH_fs.asp?view=treatment: at this site, enter “Smoking Cessation” in the Search. ■“Treating Tobacco Use and Dependence: A Clinical Practice Guideline”1-800-358-9295 http://www.surgeongeneral.gov/tobacco/default.htm ■“You Can Quit Smoking”— Consumer Guide U.S. Department of Health and Human Services. http://www.mrnc.org/mrnchcqip/documents/smconsumr.pdf ■American Cancer Societyhttp://www.cancer.org1-800-227-2345 ■ ACOG Committee Opinion Number 471, November 2010 (Reaffirmed 2013, Replaces No. 316, October 2005) http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Smoking_Cessation_During_Pregnancy.aspx _____________________________________________________________________________________________________________________ Tobacco Cessation Documentation template Time in: _______ AM/PM Time Out ______ AM/PM Total Time Spent face to face ___________ HPI • Number of years you have smoked? ________ • Average number of Cigarettes per day? _____ • Other types of tobacco used: Pipe Cigar Chew Vapor • How many times have you tried to quit? _____ • At what time of day do you smoke your first cigarette? • Have you experienced recent heartburn? ___ Yes ___ No • Have you experienced Smoker’s Cough? ___ Yes ___ No • Do you have sinus problems? ___ Yes ___ No • Any specific issues you want addressed at this appointment/session? o ____________________________________________ o ____________________________________________ ROS • Has your activity level been recently limited by breathing issues? ___Yes ___ No • Any chest pain with exercise? ___ Yes ___ No • Any problems with insomnia? ___ Yes ___ No Past Medical History:______________________________________ Medications (Including OTC) _______________________________ ________________________________________________________ EXAM: Weight________ Blood Pressure ___/___ BMI____________ Peak Flow __________ (if done) DISCUSSION & PLAN  Quit Date Planned _____________________________________________________________  Behavioral Options to Quit reviewed _______________________________________________  Medication Options reviewed. Risks, Benefits and side effects discussed and questions answered ______________________________________________________________________________  Medication prescribed ____________________________________________________________  Additional Plan(s)_______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Provider Signature___________________________________________ Date_____________ CODING:  99406/G0436 Smoking Cessation 3-10 Minutes  99407/G0437 Smoking Cessation Greater than 10 Minutes  94150 Peak Flow _______________________________________________________________________________________________________________________________________ Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/