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Preventive care coding for smoking cessation explained


Various areas of coding, including preventive care, smoking cessation, are addressed

Key Points

Q: What am I doing wrong in coding below? Should I exclude 305.1 and 493.90 from 99205 and 99385? 99205 25 493.90, 786.2, 477.9, 305.1 99385 25 493.90, 786.2, 477.9, 305.1
99407 25 305.1 - Insurance didn't pay ("Not separately reimbursable service")94010 25 305.194375 493.90 - Insurance didn't pay ("Not separately reimbursable service")

A: These are very good questions that include several areas of coding, which I will address separately.

Modifier 25: As the description indicates, this modifier is for a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" and should be appended to E/M services only. Therefore, the 25 modifier would not be appropriate to append to 94375 or 94010.

94375 and 94010: According to National Correct Coding Initiative edits, 94375 (respiratory flow volume loop) is a component of 94010 (spirometry), so 94375 cannot be billed in addition to 94010.

Tobacco cessation codes: The following are some tips.

• Treat smoking cessation documentation as you would a surgical procedure during an E/M and document it separately. The documentation doesn't have to be in a completely separate note, but documenting in a separate part of the note helps distinguish the smoking cessation service from any other E/M services provided. If you want to code for both services, then documentation must show that the behavior change intervention is distinct from the E/M service. Therefore, in your example, diagnosis code 305.1 should be billed only with the smoking cessation codes.

• Remember that these codes require documented, true "behavior change intervention" on your part, beyond merely advising patients that their health would improve should they cease smoking. This intervention should include a discussion (not a lecture) with the patient regarding his or her readiness to change, specific methods to address barriers to change and avoid relapse, prescribing pharmacologic interventions, and suggesting community support groups.

• Because these are time-based codes, you must document the time spent on the smoking cessation services. Less than 3 minutes is included in the E/M service. Three to 10 minutes qualifies for code 99406, and greater than 10 minutes qualifies for 99407.

• If you're billing Medicare, then documentation must support the presence of a condition and/or treatment being affected adversely by tobacco use; the provider needs to document why the patient should stop smoking, over and above just being healthy. In your example, 493.90 would be the type of diagnosis Medicare would want. In situations in which you have fully documented the smoking cessation, you should appeal the denial of this code and send the supporting documentation with the appeal.

The author is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Have a coding or managed care question for our experts? Send it to

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Jennifer N. Lee, MD, FAAFP
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