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. The Affordable Care Act (ACA) and other federal laws and rules require most health insurance plans in the U.S. to cover some level of tobacco cessation treatments.
Details about Medicare coverage for tobacco cessation treatments are below.
Who is Covered?
- Age 65+ or some disabled individuals
Covered Medications
- Cessation medications: nicotine nasal spray, nicotine inhaler, bupropion and varenicline.
- Part D plans may opt to cover other medications.
Covered Counseling
- 4 sessions of individual counseling
- Up to 2 quit attempts per year
- No cost-sharing for counseling
- Annual prevention visit
- Telehealth Service for smoking cessation—including outpatient, inpatient, and emergency department—is covered.
- Providers eligible for reimbursement are physicians, physician assistants and nurse practitioners, pharmacists, clinical nurse specialists, qualified psychologists, and clinical social workers.
Billing for Outpatient and Hospitalized Patients
99406, smoking and tobacco cessation counseling, intermediate, 3-10 minutes
99407, smoking and tobacco cessation counseling, intensive, greater than 10 minutes.
(NCD 210.4 Smoking and Tobacco Use Cessation Counseling).
Contractors shall allow payment for a medically necessary Evaluation and Management service on the same day as the counseling to prevent tobacco use service when it is clinically appropriate. Physicians and qualified non-physician practitioners shall use an appropriate HCPCS code, such as HCPCS 99201–99215, to report an Evaluation and Management service with “-25 modifier” to indicate that the Evaluation and Management service is a separately identifiable service from 99406 or 99407.
Limits
Group therapy, telephone and web-based counseling are NOT covered. However, the Wisconsin Tobacco Quit Line is free and is available 24/7 to assist all Wisconsin residents who want to quit:
- Call 800-QUIT-NOW (800-784-8669)
- Click here
For Further Information
