- Counseling to Prevent Tobacco Use and Tobacco Related Diseases Job Aid
- Coverage Criteria and Frequency Limits
- Checking Medicare Eligibility
- Top Tobacco Counseling Claim Errors
- Tobacco Cessation Telehealth Guide
- Overcoming Barriers to Tobacco Counseling
- Tobacco Counseling Documentation
- Clinical Guidelines and Recommendations
- Frequently Asked Questions
- Federally Qualified Health Center
- Rural Health Clinic
- Tobacco and Health Effects
- Benefits of Quitting
- Lung Cancer Screening
- Resources
Federally Qualified Health Center
Table of Contents
Counseling to Prevent Tobacco Use
Coverage for tobacco cessation counseling for outpatient 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 (PA or NP).
Medicare covers 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 in which 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.
Billing FQHC for Smoking and Tobacco Cessation Services
Medicare pays FQHCs based on the FQHC PPS for medically necessary primary health services and qualified preventive health services from an FQHC physician or nonphysician practitioner.
If the only service performed is the smoking and tobacco use cessation counseling, report the counseling as the billable encounter. This claim will generate a PPS payment.
However, if there is another billable encounter on the same date of service, including the IPPE, the smoking and tobacco use cessation counseling would be reported as incident-to the encounter and would not generate additional payment. Reimbursement would be included as part of the PPS payment.
When billing the smoking and tobacco use cessation counseling as the encounter, an FQHC reports the following on a UB04 or electronic Part A claim:
- Payment code line using 052X revenue code, payment code G0467, one unit of service, and the FQHC’s payment code charges.
- Qualifying visit line using 052X revenue code, CPT code 99406 or 99407, one unit of service, and the actual charges for the counseling.
- Revenue code 0001 Totals line that sums the totals of the above claim lines.
Example: Smoking and tobacco use cessation counseling as the only service provided on DOS.
| Rev Code | Description | HCPCS | Service Date | Service Units | Total Charges |
|---|---|---|---|---|---|
| 0521 | Medical encounter, established patient | G0467 Payment Code |
1/1/2022 | 1 | Facility's Payment code charge |
| 0521 | Smoking and tobacco use cessation counseling | 99406 or 99407 Qualifying Visit | 1/1/2022 | 1 | Actual charge |
| 0001 | Total | Sum of above charges |
This claim would generate a PPS payment.
When billing the smoking and tobacco use cessation counseling as incident-to the encounter, an FQHC reports the following on a UB04 or electronic Part A claim:
- Payment code line using 052X revenue code, appropriate payment code, one unit of service, and the FQHC’s payment code charges.
- Qualifying visit line using 052X revenue code, HCPCS/CPT code to identify the billable visit, one unit of service, and the actual charges for the visit.
- Incident-to line using revenue code 0942, CPT code 99406 or 99407, one unit of service, and the actual charges for the counseling.
- Revenue code 0001 Totals line that sums the totals of the above claim lines.
Example: Smoking and tobacco use cessation counseling provided on same DOS as billable encounter.
| Rev Code | Description | HCPCS | Service Date | Service Units | Total Charges |
|---|---|---|---|---|---|
| 0521 | Medical encounter, established patient | G0467 Payment Code |
1/1/2022 | 1 | Facility's Payment code charge |
| 0521 | Billable encounter service | Qualifying Visit HCPCS/CPT code | 1/1/2022 | 1 | Actual charge |
| 0942 | Smoking and tobacco use cessation couneling | 99406 or 99407 Incident-to service | 1/1/2022 | 1 | Actual charge |
| 0001 | Total | Sum of above charges |
This claim would generate a PPS payment (without additional reimbursement).
The beneficiary copayment is waived by the Affordable Care Act for Medicare-covered preventive services recommended by the United States Preventive Services Task Force with a grade or A or B, which includes the smoking and tobacco use cessation counseling.
Related Content
- Centers for Medicare & Medicaid Services (CMS) Federally Qualified Health Centers (FQHC) Center
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 12
- CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Part 4, Section 210.4.1
- MLN® Educational Tool:Medicare Preventive Services
- MLN® Booklet: Federally Qualified Health Center
Reviewed 10/10/2024