Preventive Services

Preventive Services Guide


Counseling to Prevent Tobacco Use

Smoking is the leading preventable cause of disease, disability and death in the United States. It harms nearly every organ in the body and causes about one in every five deaths.

Coverage for tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries include those:

  • who use tobacco, regardless if they have signs or symptoms of tobacco-related disease,
  • who are competent and alert at the time counseling is provided, and
  • whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

Coverage Criteria and Frequency Limits

Counseling to Prevent Tobacco Use

  • 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 eight sessions per year in a 12-month period:
      • 99406: Intermediate – more than three minutes up to ten minutes
      • 99407: Intensive – more than ten minutes
    • To start the count for the second or subsequent 12-month period, begin with the month after the month the first Medicare covered counseling session was performed and count until 11 full months have elapsed
  • Diagnosis coding
    • F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A and Z87.891
    • Additional ICD-10 codes may apply
  • When clinically appropriate, medically necessary E/M same day as counseling to prevent tobacco use
    • Use appropriate HCPCS code such as 99202–99215 to report E/M same-day service with modifier 25 to indicate separately identifiable service

Cost Sharing

  • Copayment/coinsurance waived
  • Deductible waived

Reimbursement

Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

Common Claim Denial Reasons

  • The information provided does not support the need for this service or item.
  • Missing/incomplete/invalid diagnosis.
  • Services cannot be paid because benefits are exhausted at this time.
  • Benefit maximum for this time period or occurrence has been reached.
  • Number of days or units of service exceeds acceptable maximum.

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Reviewed 9/27/2024