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National Coverage Determination (NCD)

Smoking and Tobacco-Use Cessation Counseling

210.4

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Tracking Information

Publication Number
100-3
Manual Section Number
210.4
Manual Section Title
Smoking and Tobacco-Use Cessation Counseling
Version Number
1
Effective Date of this Version
03/22/2005
Ending Effective Date of this Version
09/26/2017
Implementation Date
07/05/2005
Implementation QR Modifier Date

Description Information

Benefit Category
Clinical Social Worker Services
Incident to a physician's professional Service
Outpatient Hospital Services Incident to a Physician's Service
Physicians' Services
Qualified Psychologist Services
Rural Health Clinic 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 continues to be the leading cause of preventable death in the United States. In 1964, the Surgeon General of the U.S. Public Health Service (PHS) issued the report of his Advisory Committee on Smoking and Health, officially recognizing that cigarette smoking is a cause of cancer and other serious diseases. Though smoking rates have significantly declined, 9.3% of the population age 65 and older smokes cigarettes. Approximately 440,000 people die annually from smoking related disease, with 68% (300,000) age 65 or older. Many more people of all ages suffer from serious illness caused from smoking, leading to disability and decreased quality of life. Reduction in smoking prevalence is a national objective in Healthy People 2010.

Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective March 22, 2005, the Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that smoking and tobacco use cessation counseling, based on the current PHS Guideline, is reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use, or who is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on FDA-approved information.

Patients must be competent and alert at the time that services are provided. Minimal counseling is already covered at each evaluation and management (E&M) visit. Beyond that, Medicare will cover 2 cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions in a 12-month period. The practitioner and patient have flexibility to choose between intermediate or intensive cessation strategies for each attempt.

Intermediate and intensive smoking cessation counseling services will be covered for outpatient and hospitalized beneficiaries who are smokers and who qualify as above, as long as those services are furnished by qualified physicians and other Medicare-recognized practitioners.

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

NA

(This NCD last reviewed May 2005.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
36
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R36NCD.pdf
Revision History

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)

05/2005 - Covered two new levels of counseling for smoking cessation (intermediate and intensive). Effective Date 03/22/2005 Implementation Date 07/05/2005. (TN 36) (CR 3834)
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
Smoking and Tobacco-Use Cessation Counseling - RETIRED 3 04/10/2023 - N/A View
Smoking and Tobacco-Use Cessation Counseling - RETIRED 2 09/30/2015 - 04/10/2023 View
Smoking and Tobacco-Use Cessation Counseling 1 03/22/2005 - 09/26/2017 You are here
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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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