Tobacco use is still the most common cause of preventable disease in the United States.
Patients who qualify for Medicare are more likely to use or have used tobacco products in the past than most other patients. It wasn’t until 1970 that the Surgeon General’s warning regarding smoking began to appear on cigarette packages. This clearly shows that most Baby Boomers and their parents generation didn’t have warnings about tobacco use until they were adults.
Today we know that nicotine is very addictive. When you combine this with recent admissions of tobacco companies that they intentionally made their products more addictive, it is easy to understand why so many Medicare patients are still struggling with quitting.
The negative effects of smoking and other uses of tobacco are rather well known today with cancer being the number one concern. Patients know that tobacco use can also cause heart attacks, strokes and other forms of disease, but knowing doesn’t lead to quitting. In our article on behavioral change, we discussed how motivation to change usually requires conflict that outweighs the perceived benefits of a habit.
Example of Conflict Motivation in Tobacco Cessation:
Both my in-laws were avid smokers throughout their lives. At age 68, my mother-in-law’s coughing became so intense she was concerned it would lead to cancer. It wasn’t until that time that she was motivated to stop. My father in law took longer. He developed unexplained painful neuropathy in his feet. After a multitude of tests, his doctor recommended that he stop smoking, assuming that the restricting effect smoking can have on blood vessels may be the culprit. His pain was so intense, he was motivated at that time to stop.
Helping patients identify their motivation may be helpful in their effort to stop smoking.
There is an abundance of research that has been done over the past 40 years regarding the impact tobacco use has on patient’s health. One of the most interesting study is a 2013 study that found that even brief interventions can have a significant impact on patient’s decision to quit.
The USPSTF’s Recommendations:
Because of the known impact smoking and other tobacco use has on patient’s health, the USPSTF now recommends that all adults be asked about their tobacco use. As the 2013 study (previously discussed) demonstrated, even brief discussions can have an impact on your patient population. However, it is advised that providers have a much more dynamic approach to tobacco cessation. Because of the USPSTF’s recommendation, Medicare now reimburses providers for providing tobacco cessation services.
Medicare’s Tobacco Cessation Services:
Since 2010, there have been changes to the Tobacco cessation services offered by Medicare. Initially, Medicare funded separate codes based upon symptomatic and asymptomatic patients. Since that time, these G-codes have been deleted and the services are now billed under two distinct codes: 99406 and 99407 based strictly on time. Like the G-codes, there is no copay required for these visits as they are considered a preventive service.
Medicare allows patients to attempt cessation twice in a 12 month period. Each attempt includes 4-sessions with providers, for a total of up to 8 visits per year. Medicare defines these two codes as follows:
99406 – Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes; and
99407 – Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes.
It is important to note that providers must document the amount of time spent on smoking cessation during the visit in order to be reimbursed for these codes.
With the deletion of the former G-codes the regulations on how these visits are to be performed has been minimized. Unlike the Medicare Annual Wellness Visit and as with any other codes, an approved healthcare professional (MD, DO, NP or PA) must be the one who performs this visit.
5 A’s and 5 R’s
Medicare no longer requires that providers use the 5 A’s during the tobacco cessation sessions. That being said, the USPSTF have found the 5 A’s to be very useful in providing a framework for providers to use in the limited time available for tobacco cessation counseling.
For patients who are actively using tobacco and are not quite ready to quit, we recommend providers use the 5 R’s to help prepare patients for cessation in the future. You can find a description of the 5 R’s and 5 A’s in our article about behavioral interventions within your practice.
Utilizing your Wellness Team:
Although the wellness team may not perform this visit without a provider’s involvement, we highly recommend each practice’s wellness team be trained on effective tobacco cessation. These experts can play a significant role in providing behavioral supports to patients who are currently using tobacco. Similar to the role LPNs and RNs play currently, the wellness nurse can be given the responsibility of providing patient education/literacy, advise and agree upon a plan prior to the patient seeing the provider. Using the 5 A’s the provider can then Assist and Arrange for continued supports. It is imperative to note however that to bill Medicare for tobacco cessation services, a medical provider must see the patient prior to billing for the services.
Quality Measures Met:
This table is provided to demonstrate how some quality measures may be met by utilizing tobacco cessation services in the practice:
|Tobacco Assessment and Cessation Advice||X||X||X||X||X|
Federally Qualified Health Centers:
FQHCs bill based upon the new Prospective Payment System (PPS) which is a flat rate agreed upon by CMS. A FQHC may not bill for services not listed within the PPS system. Both 99406 and 99407 are listed as services billable by FQHCs using the PPS rate.
CMS has interpreted the Social Security Act to state that a provider must see all patients who come to the FQHC for care before billing may occur. As with the Fee for Service providers, the provider should be included in the tobacco cessation process. The wellness team should still play a significant part of the visit but it is important to note that CMS’s Regulations and Guidance paper states:
“When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered “incident to” and do not constitute a billable visit.”
To avoid the “incident to” scenario, the FQHC must define clearly what the wellness staff will do during the tobacco cessation visits delineating the appropriate activities that can be done by the wellness staff and what must be done by the provider. Unlike other behavioral intervention services, CMS does not require the USPSTF’s 5 A’s to be used during this visit. However, using the 5 A’s as a framework will allow the practice to assign appropriate responsibilities to the staff. (We recommend the practice set the wellness program up similar to how a regular E&M service works… LPNs and RNs are assigned tasks and the provider follows up with the appropriate patient interactions.)
According to the USPSTF Final Recommendation Statement, “Approximately 69% of adults who smoke daily report interest in quitting, and roughly 43% attempted to quit in the previous year.” Given the public health significance of the consequences of tobacco use, it is highly recommended that primary care providers take a much more active role in providing tobacco cessation services to their patients.
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For more information about our preventive service recommendations see the following articles:
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