September 26, 2019
Last Reviewed Date:
February 23, 2023
Provides guidelines for smoking cessation claim payment when appropriately billed by professional providers
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- ITS Home In-Network
- SHBP non MA
All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.
ASO accounts will be included as an Opt-In option for additional claims editing on an account by account basis
In accordance with CMS guidelines, Horizon BCBSNJ shall consider for reimbursement smoking and tobacco cessation counseling visits (99406 or 99407) for asymptomatic patients when billed with an approved diagnosis code.
Approved Diagnosis Codes:
- Nicotine dependence (F17.21-F17.299)
- Personal history of nicotine dependence (Z87.891)
- Initial encounter, toxic effect of tobacco and nicotine (T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A)
Evaluation and management (E&M) services shall be considered for reimbursement on the same day as smoking and tobacco-use cessation counseling services (99406 or 99407) only when medically necessary, as indicated by appending Modifier 25 to the E&M service.
Also, in keeping aligned with CMS guidelines, Horizon BCBSNJ shall limit smoking and tobacco-use cessation counseling (99406 or 99407) in any combination to eight times within a one-year period.
The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
Horizon BCBSNJ shall deny 99406 or 99407 (Smoking and tobacco cessation counseling visit) when billed without an approved diagnosis of nicotine dependence, toxic effect of tobacco and nicotine, or personal history of tobacco use as provided above.
Horizon BCBSNJ shall deny 99201-99397 or 99420-99499 (E&M service) when billed with 99406 or 99407 (Smoking and tobacco cessation counseling visit) on the same date of service and modifier 25 is not appended to the E&M service.
Horizon BCBSNJ shall deny 99406 or 99407 (Smoking and tobacco cessation counseling visit) when billed in any combination of more than eight units in a one-year period by the same of different provider.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
07/22/2019: Policy approved