[HealthyTribes] Medicaid Cessation Billing Information

[Sanders Elizabeth C]

Hello, as a follow up to today's TPEP call, I'm sharing with you information on which health professionals can bill for tobacco cessation services for Oregon Health Plan members. Please refer to OAR 410-130-0190<http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_130.html> "Tobacco Cessation" for more details. I will work on posting this to the cessation page of HPCDP connection.

Thanks, Beth
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In Oregon, CPT codes 99406, 99407 (cessation counseling)  are open to payment to the following providers:
            34 - physician
            38 - advanced comp health care (includes naturopathic physician)
            42 - Advance Practice Nurse
            46 - Physician Assistants
            47 - Clinic
38 - advanced comp health care (includes naturopathic physician)
and 47 - Clinic are not covered by the federal guidelines.

In Oregon, CPT codes G0436 and  G0437(cessation counseling)  are open to payment to the following services:
            34 - physician
            42 - Advance Practice Nurse
            46 - Physician Assistants


December 28, 2012 Rulebook

Oregon Administrative Rule 410-130-0190 Tobacco Cessation

(1) Tobacco treatment interventions may include one or more of these services: basic, intensive, and telephone calls.

(2) Basic tobacco cessation treatment includes the following services:

(a) Ask -- systematically identify all tobacco users -- usually done at each visit;

(b) Advise -- strongly urge all tobacco users to quit using;

(c) Assess - the tobacco user's willingness to attempt to quit using tobacco within 30 days;

(d) Assist -- with brief behavioral counseling, treatment materials and the recommendation/prescription of tobacco cessation therapy products (e.g., nicotine patches, oral medications intended for tobacco cessation treatment and gum);

(e) Arrange -- follow-up support and/or referral to more intensive treatments, if needed.

(3) When providing basic treatment, include a brief discussion to address client concerns and provide the support, encouragement, and counseling needed to assist with tobacco cessation efforts. These brief interventions, less than 6 minutes, generally are provided during a visit for other conditions, and additional billing is not appropriate.

(4) Intensive tobacco cessation treatment is on the Health Services Commission's Prioritized List of Health Services and is covered if a documented quit date has been established. This treatment is limited to ten sessions every three months. Treatment is reserved for those clients who are not able to quit using tobacco with the basic intervention measures.

(5) Intensive tobacco cessation treatment includes the following services:

(a) Multiple treatment encounters (up to ten in a 3 month period);

(b) Behavioral and tobacco cessation therapy products (e.g., nicotine patches, oral medications intended for tobacco cessation treatment and gum);

(c) Individual or group counseling, six minutes or greater.

(6) Telephone calls: the Division may reimburse a telephone call intended as a replacement for face-to-face contact with clients who are in intensive treatment as it is considered a reasonable adjunct to, or replacement for, scheduled counseling sessions:
(a) The call must last six to ten minutes and provides support and follow-up counseling;

(b) The call must be conducted by the provider or other trained staff under the direction or supervision of the provider;

(c) Enter proper documentation of the service in the client's chart.

(7) Diagnosis Code ICD-9-CM 305.1 (Tobacco Use Disorder):

(a) Use as the principal diagnosis code when the client is enrolled in a tobacco cessation program or if the primary purpose of the visit is for tobacco cessation services;

(b) Use as a secondary diagnosis code when the primary purpose of this visit is not for tobacco cessation or when the tobacco use is confirmed during the visit.

(8) Billing Information: Managed care plans may have tobacco cessation services and programs. This rule does not limit or prescribe services a Prepaid Health Plan provides to clients receiving the Basic Health Care Package.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025, 414.065

Beth Sanders, MPH
Cessation Coordinator
Center for Prevention and Health Promotion | Oregon Public Health Division
800 NE Oregon St., Suite 730 | Portland, Oregon 97232 | (971) 673-0563
elizabeth.c.sanders at state.or.us
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