Reimbursement for tobacco cessation: New models for fee for service and ACO/capitation
Tobacco cessation services provided by medical practitioners do not appear to be effective. According to the most recent Surgeon General’s Report, each year only 7.6 percent of smokers are able to stop. Although smokers report that doctors advise them to quit smoking, only one third of smokers making quit attempts use evidence-based interventions such as medication or counselling. As a result, relapse rates are high, and some smokers require up to 20 attempts before they are successful. Smokers with higher burden of social determinants of health are even less likely to receive cessation services. Although many barriers to systematic implementation of tobacco cessation services have been identified, the least well studied is the role of reimbursement and overall practice income.
Most clinicians do not bother billing for add on codes 99406 or 99407 because of the low reimbursement rates. My data shows that this occurs even when they provide counselling, refer to the quit line, and prescribe cessation medication. The impact of routine counselling can be substantial for the patient and the practice revenue. EMR data from Wellspan, a health system in Pennsylvania and Maryland, was modeled to show what might occur if every encounter eligible for tobacco cessation services were billed. A Lost Opportunity in Tobacco Cessation: Care: Impact of Underbilling in a Large Health System - ScienceDirect. The three-year estimate for maximal billing was $5.9M
· Clinical practice guidelines support an evidence-based intervention for every smoker, every visit, regardless of their readiness to change. Scheduled follow-ups to counselling double the impact of any intervention, and additional sessions further enhance outcomes. Cessation interventions apply to all types of tobacco.
· CMS guidelines, adopted by most payors allow up to eight sessions per year.
Counseling to Prevent Tobacco Use (ngsmedicare.com)
· The American Lung Association has clear guidelines for documentation standards.
https://www.lung.org/getmedia/275e15df-413d-450f-9bed-b98a9fb04e1a/ala-billing-guide-2021.pdf
· CMS recently determined that the add-on codes for tobacco cessation counseling 99406 and 99497 are incident to the basic evaluation and management services and can be provided by any staff in the office.
Details on CMS requirements for documentation, billing and coding are available here
· Resources and tools to support changes in office workflow and other systems change:
Tobacco Cessation Change Package (hhs.gov) (The Million Heart Initiative)
American Academy of Family Practice Office Champions
Practice leaders and administrators are invited to “do the math” and estimate the impact. Follow the link to an XL spreadsheet that supports an estimate of the reimbursement based on billing every smoker for a 3-minute counselling cessation. . Go to the XL Worksheet here to do the math for your practice. References and tools are a click away.
Some clinicians have stopped coding for tobacco cessation because reimbursement is capitated or linked to accountable care contracts. Almost half of medical services delivered today are not reimbursed as fee-for-service and the proportion is increasing. Most practices have mixed payment arrangements. Yet tobacco cessation is one of the few preventive services that produce a return on investment (ROI). Published reports show an ROI ranging from 3:1 to 10:1. You can find a summary of this literature here. A recent article shows that the well-established return on investment can be shown within one year. Cost-Effectiveness of a Comprehensive Primary Care Smoking Treatment Program - ScienceDirect. The is no doubt that additional savings will accrue in subsequent years.
The cost of implementing systems-based improvements in smoking cessation is modest and the benefits continue to accrue and increase over future years that members are retained.
Details on CMS requirements for documentation, billing and coding are available here
Please share your thoughts and questions with me.
Edward Anselm, MD Clinical Assistant Professor, Icahn School of Medicine at Mount Sinai
eanselm@MSN.com