Tobacco Cessation

Tobacco Counseling Documentation

Many healthcare providers perform tobacco use counseling, but they may not be documenting or reporting it appropriately. Providers must ensure all performed services are claimed and supported by complete documentation.

Smoking cessation documentation should reflect the performance of a significantly separate identifiable service when it is performed on the same date of service as an E/M service.

As with any time-based E/M service, documentation must include sufficient detail to support the claim. Proper documentation for tobacco-use cessation counseling should include the total time spent face-to-face with the patient, and what was discussed.

The patient’s desire or need to quit tobacco use, cessation techniques and resources, estimated quit date, and planned follow up should be noted in the patient’s medical record. Without this information, medical necessity for coverage may be questioned, which could result in denied or delayed payment.

Elements of documentation for CPT codes 99406-99407 may include, but are not limited to:

  • Type or method of tobacco use (cigarettes, pipe, chewing tobacco, etc.)
  • Amount of use (i.e., asking if the use qualifies as dependence)
  • Impact (personal considering comorbidities)
  • Impact (family, friends, health, social, financial, etc.)
  • Methods and skills for cessation
  • Resources available
  • Willingness to attempt to quit
  • If the patient is willing to attempt to quit, agreement on plan of approach
  • Implementation date
  • Method of follow up
  • Documentation of exact time spent in face-to-face counseling with the patient

The method of documentation should mirror those methods that would be used in typical physician practice with patient visits.

As with any claim, Medicare may decide to conduct postpayment reviews to determine that the services provided are consistent with coverage instructions. Providers must keep patient record information on file for each Medicare patient for whom a counseling claim is made. These medical records can be used in any postpayment review and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.

Best Practice Sample Documentation

We spent 15 minutes today discussing the patient’s current one-pack per day cigarette dependence; the effects of smoking on her diabetes and family (secondhand smoke); and a counseling plan for quitting. After discussing pharmacotherapy options, the patient elected to begin starter-pack Chantix and use the gradual quit approach. A goal was set to be smoke free within the next six weeks. I will follow up in one week to check progress.

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Revised 10/9/2023