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National Coverage Determination (NCD)

Counseling to Prevent Tobacco Use

210.4.1

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Tracking Information

Publication Number
100-3
Manual Section Number
210.4.1
Manual Section Title
Counseling to Prevent Tobacco Use
Version Number
2
Effective Date of this Version
09/26/2017
Ending Effective Date of this Version
Implementation Date
09/26/2017
Implementation QR Modifier Date

Description Information

Benefit Category
Additional Preventive Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A. General

Tobacco use remains the leading cause of preventable morbidity and mortality in the U.S. and is a major contributor to the nation’s increasing medical costs. Despite the growing list of adverse health effects associated with smoking, more than 45 million U.S. adults continue to smoke and approximately 1,200 die prematurely each day from tobacco-related diseases. Annual smoking-attributable expenditures can be measured both in direct medical costs ($96 billion) and in lost productivity ($97 billion), but the results of national surveys have raised concerns that recent declines in smoking prevalence among U.S. adults may have come to an end. According to the U.S. Department of Health and Human Services (DHHS) Public Health Service (PHS) Clinical Practice Guideline on Treating Tobacco Use and Dependence (2008), 4.5 million adults over 65 years of age smoke cigarettes. Even smokers over age 65, however, can benefit greatly from abstinence, and older smokers who quit can reduce their risk of death from coronary heart disease, chronic obstructive lung disease and lung cancer, as well as decrease their risk of osteoporosis.
Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries

  1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
  2. Who are competent and alert at the time that counseling is provided; and,
  3. Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

Intermediate and intensive smoking cessation counseling services will be covered under Medicare Part B when the above conditions of coverage are met, subject to frequency and other limitations. That is, similar to existing tobacco cessation counseling for symptomatic individuals, CMS will allow 2 individual tobacco cessation counseling attempts per 12-month period. Each attempt may include a maximum of 4 intermediate OR intensive sessions, with a total benefit covering up to 8 sessions per 12-month period per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than 3 minutes but less than 10 minutes), or intensive (more than 10 minutes) cessation counseling sessions for each attempt.

C. Nationally Non-Covered Indications

Inpatient hospital stays with the principal diagnosis of tobacco use disorder are not reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, we will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient’s hospital stay.

D. Other

Section 4104 of the Affordable Care Act provided for a waiver of the Medicare coinsurance and Part B deductible requirements for this service effective on or after January 1, 2011. Until that time, this service will continue to be subject to the standard Medicare coinsurance and Part B deductible requirements.

(This NCD last reviewed December 2016.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
202
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R202NCD.pdf
Revision History

02/2018 - Transmittal 2033, dated February 16, 2018, is being rescinded and replaced by Transmittal 2039, dated, February 28, 2018 to correct instructions in business requirement 7, NCD210.3, Colorectal Cancer Screening, and its accompanying spreadsheet. All other information remains the same. (TN 2039) (CR10473)

02/2018 - This Change Request (CR) constitutes a maintenance update of International Code of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.

Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html, along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. (TN 2033) (CR10473)

08/2017 - This Change Request (CR) revises Pub. 100-04, chapters 18 and 32 to update claims processing instructions for smoking cessation services implemented in CR 9768 and colorectal screening services. This CR also revises Chapter 32, cardiac rehabilitation programs, to update coverage policy. This CR also revises Pub. 100-03, Chapter 1 sections. These changes are intended only to clarify existing policy and no system or processing changes are anticipated. Effective date 09/26/2017 Implementation date 09/26/2017 (TN 202) (CR10199)

07/2017 - This Change Request (CR) constitutes a maintenance update of International Code of Diseases, Tenth Revision (ICD-10) conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html, along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. (TN 1875) (CR10184)

06/2016 - Transmittal 1665, dated May 13, 2016, is being rescinded and replaced by Transmittal 1672 to: (1) 9631.1: Remove FISS responsibility and 1st sentence; (2) 9631.2: Remove additional procedure codes, including 0075T, 0076T; (3) 9631.4: Revise descriptor of dx L59.8; (4) 9631.6: Add deletion of dx C49.10, C65.9, remove deletion of dx C54.9, remove deletion of invalid dx C47.90; (5) 9631.8: Remove deletion of invalid dx C51.29, replace with deletion of dx C50.029; (6) 9631.9: Add deletion of 0V504ZZ, 0V500ZZ, override capability, and contractor discretion verbiage. All other information remains the same. (TN 1672) (CR9631)

05/2016 - This change request (CR) is the 7th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, CR9252, and CR9540. Some are the result of revisions required to other NCD-related CRs released separately. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. (TN 1665) (CR9631)

03/2013 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy. Implementation date: 10/07/2013 Effective date: 10/1/2015. (TN 1199) (TN 1199) (CR 8197)

09/2010 - These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations. Effective date 08/25/2010 Implementation date 01/03/2011 (TN 126) (CR 7133)

09/2010 - Effective for claims with dates of service on and after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:

  1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
  2. Who are competent and alert at the time that counseling is provided; and
  3. Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Counseling to Prevent Tobacco Use 2 09/26/2017 - N/A You are here
Counseling to Prevent Tobacco Use 1 08/25/2010 - 09/26/2017 View
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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