Quit Tobacco Series Fact Sheets #4: Medicare

The U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence recommends the combination of medication and counseling for every patient who uses tobacco.

Qualified Beneficiaries
Medicare covers counseling to treat tobacco use for outpatient and hospitalized beneficiaries:

Who use tobacco (regardless of signs or symptoms of tobacco-related disease).

Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

Covered Medications
Every drug plan is required by Medicare to cover at least one of these FDA-approved medications:

* Bupropion SR 150 (generic or Zyban)

* Nicotine inhaler

* Nicotine nasal spray

* Nicotine patch (prescription)

* Varenicline (Chantix)


Covered Counseling
Clinicians can at least double quit rates by following the clinical practice guideline recommendation to counsel patients to quit. Medicare covers two individual cessation attempts per 12 month period per patient. Each attempt may include a maximum of four intermediate (3-10 minutes) or intensive (more than 10 minutes) sessions with the total annual benefit covering up to eight sessions in a 12 month period. Telehealth Service for smoking cessation—including outpatient, inpatient, and emergency department—is now covered. Providers eligible for reimbursement are physicians, physician assistants and nurse practitioners, clinical nurse specialists, qualified psychologists and clinical social workers.

For symptomatic patients: 99406, smoking and tobacco cessation counseling, intermediate, 3-10 minutes; 99407, smoking and tobacco cessation counseling, intensive, greater than 10 minutes.

For asymptomatic patients: Effective October 1, 2016, codes G0436 and G0437 are deleted and replaced with 99406 and 99407 (NCD 210.4 Smoking and Tobacco Use Cessation Counseling).

ICD-10 Diagnostic Codes

Note: Medicare will allow payment for a medically necessary E/M service on the same date as tobacco cessation counseling, provided it is clinically appropriate. Use modifier 25 to indicate a separately identifiable service.

Group therapy, telephone and web-based counseling are NOT covered. However, the
Wisconsin Tobacco Quit Line is free and is available to assist all Wisconsin residents who want to quit: 800-QUIT-NOW (800-784-8669); Available 24/7.

For Further Information