To the Editor: In March 2005, Medicare approved reimbursement for tobacco cessation counseling for patients with smoking-related illnesses. The temporary billing codes established in 2005 cover counseling sessions of 3 to 10 minutes or longer than 10 minutes for patients who use tobacco products and have a smoking-related illness as defined by the U.S. Surgeon General. The coverage includes two attempts per year, defined as up to four counseling sessions per attempt. It was hypothesized that billing for tobacco cessation counseling in Medicare beneficiaries may be underused.
In this retrospective study in an outpatient university practice, all Medicare patient visits and their billing codes between March 2005 and May 2008 were reviewed. Visits for which nicotine dependence (International Classification of Diseases, Ninth Revision, codes 305.1, V15.82, 292) was one of the first three diagnoses were searched for. Of visits billed for tobacco use counseling (Common Procedural Terminology (CPT) codes G0375, G0376, 99406, 99407), the billing records for payments received, primary care versus specialist providers, and the timing of the visits were analyzed. Of visits not billed for tobacco use counseling, the medical charts were categorized based on the documented counseling provided.
Of 36,873 individual visits, 240 (0.007%) were coded with a diagnosis of tobacco dependence. Of these 240 visits, only 43 (17.9%) were billed for smoking cessation counseling, of which 33 (76.7%) received reimbursement from Medicare at an average of $12.13 per visit. Twenty-nine (67.4%) were primary care encounters and the remaining 14 (32.6%) were specialist encounters. Billing took a full year between initiation of the codes to implementation, peaked in late 2006, and fell again after Medicare updated the codes in January 2008 (Figure 1).
Of the 197 nonbilled visits, four (2.0%) had proper documentation to bill, 49 (24.9%) had more than minimal documentation of counseling, 53 (26.9%) had minimal documentation, 67 (34.0%) had no documentation, and 24 (12.0%) could not be evaluated because charts were not being available.
This study shows that Medicare billing for tobacco cessation counseling is greatly underused in a university practice. More than half of the visits documented at least minimal smoking cessation counseling, representing potential missed opportunities for billing. Previous studies report that physicians correctly use CPT codes in concordance with the services they provide; thus underuse is probably due to reasons other than simply forgetting to bill—such as physicians not being aware of the billing opportunities for tobacco cessation counseling.1,2 Other reasons that counseling may not have been billed are that the counseling advice was less than 3 minutes long or that patients complain about being billed for this service. Finally, some providers may not agree with charging patients for this service.
Of providers who billed for counseling, two-thirds were primary care physicians as opposed to specialists. The fact that primary care physicians do the bulk of tobacco use counseling is not surprising, because studies show that specialists generally do not assume the responsibility of counseling for general health issues.3
In the first year since reimbursement was approved, there were no charges for these services, demonstrating a significant lag time between Medicare changes and implementation. This lag was again demonstrated when the codes changed in January 2008. Little research exists pertaining to the timing of implementation of new CPT codes in any field of medicine; this should be further investigated because it is probably a source of lost revenue.
Although this study is limited to one university practice, it is likely that other offices have similar problems implementing new insurance codes and relaying the new codes to their providers.
Suggested strategies for improvement include designating office personnel (not physicians themselves) to monitor and communicate Medicare or other insurance billing changes to medical staff. Personnel could monitor resources such as Medlearn Matters,4,5 an online publication of Medicare updates, and annual updates in organization journals.6 Alternatively, one practice's successful efforts to monitor and implement Medicare changes by outsourcing to companies that independently monitor Medicare changes has been described.7 The project kept the institution updated, maximized revenue, streamlined billing services, and increased focus on patient care.
In conclusion, billing for tobacco cessation counseling was underused in a university practice. Further research should elucidate the barriers to and solutions for implementation of reimbursement for tobacco cessation counseling. Improvements in reimbursement may encourage more providers to offer tobacco cessation counseling, thus providing a much-needed service to the aging population.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
Funding for this research was provided by the Department of Health and Human Resources Division of Tobacco Prevention.
Author Contributions: Ms. Sale and Dr. Goebel: design, data collection, and preparation of the letter. Ms. Sale: analysis.
Sponsor's Role: The study's sponsor had no role in study design, data collection, analysis, or preparation of the letter.