Does CPT 99406 Require a Modifier?

CPT code 99406 addresses tobacco cessation counseling. This code supports efforts to reduce tobacco use.

Understanding CPT Code 99406

CPT code 99406 identifies “Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 16 minutes.” This service encompasses education, brief interventions, and motivational techniques aimed at helping individuals quit tobacco products. The intermediate designation signifies a specific time commitment from the provider. This timeframe distinguishes it from shorter or more intensive counseling sessions.

Modifier Use and Specifics

CPT code 99406 does not inherently require a modifier for every submission. However, specific billing scenarios necessitate modifiers to convey additional information to payers for proper processing and reimbursement. Modifiers clarify if a service was distinct, performed in a particular context, or altered.

Modifier 25, “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service,” is frequently appended to an Evaluation and Management (E/M) service code when provided on the same day as 99406. This modifier indicates the E/M service was separate and distinct from the tobacco cessation counseling, allowing both to be reimbursed. For example, if a patient has an office visit for a chronic condition and also receives tobacco cessation counseling, modifier 25 would be added to the E/M code (e.g., 99213-25).

Modifier 33, “Preventive Services,” may be applicable when tobacco cessation counseling is provided as part of a preventive visit. This modifier signals that the service is preventive and may influence patient cost-sharing, as many preventive services are covered without copayment or deductible under certain health plans.

Modifier 59, “Distinct Procedural Service,” indicates a service was distinct or independent from other services performed on the same day. This might be relevant if 99406 is performed alongside another procedure or service that typically bundles with it, but documentation shows they were separate. For instance, if tobacco cessation counseling occurs during the same encounter as a psychotherapy session, modifier 59 would be appended to 99406.

Modifiers GX, GY, GZ, and GA relate to Medicare coverage and Advance Beneficiary Notices (ABNs). GX indicates that a service is not covered by Medicare but an ABN was issued. GY signifies that a service is statutorily non-covered by Medicare. GZ means a service is expected to be denied as not medically necessary, and no ABN was issued. GA indicates that a service is expected to be denied as not medically necessary, but an ABN was issued.

Essential Documentation Requirements

Accurate and thorough documentation is essential for justifying the medical necessity and proper billing of CPT code 99406. The patient’s medical record must clearly support that tobacco cessation counseling was provided. This includes documenting the patient’s current tobacco use status, including the type and frequency of tobacco products used.

The length of the counseling session must be recorded, often by noting the start and end times, to substantiate the “greater than 3 minutes up to 16 minutes” requirement of CPT 99406. The specific content of the counseling session is necessary, detailing topics like health risks, benefits of quitting, cessation methods, and resources provided.

Documentation should reflect the patient’s response to counseling, their willingness to attempt to quit, and any shared decision-making regarding a quit date or follow-up plan. The provider’s credentials should also be noted in the record.

Billing and Reimbursement Guidance

Submitting claims for CPT code 99406 involves adhering to general healthcare billing practices, with specific considerations for tobacco cessation services. After ensuring comprehensive documentation, the claim is typically submitted electronically to the patient’s insurance carrier. Verifying patient eligibility and benefits for counseling services before the encounter is important, as coverage can vary among different payers.

Common challenges leading to claim denials for 99406 include a lack of documented medical necessity, insufficient detail regarding counseling content, or failure to meet time requirements. Payer-specific policies vary; Medicare covers up to eight sessions per year (two cessation attempts, each with a maximum of four intermediate or intensive sessions). Commercial insurance and Medicaid plans may have different frequency limits or coverage criteria. Providers should always check individual payer policies to understand their specific rules, including whether the service is covered without patient cost-sharing.