Although people who smoke cigarettes say that clinicians routinely advise them to quit smoking, this is not reflected in the studies of electronic medical records, pharmacy claims, or medical claims. A recent article in the American Journal of Managed Care reported that only 1 percent of outpatient office visits at an academic medical center billed for tobacco treatment. A repeat of the same study design published in AJPM Focus showed that this gap in billing is widespread and, for larger health systems, may amount to millions of dollars per year.
Clinical practice guidelines recommend treatment of tobacco at every visit, so this performance gap should be alarming. Sadly, the poor performance of clinicians in the treatment of tobacco has been known for some time and has been the subject of extensive investigation of the underlying barriers. Commonly identified themes are lack of time, lack of training, poor motivation, and low reimbursement. The solutions proposed, systems change in tobacco treatment, are not commonly implemented. The increasing prevalence of value-based care may further diminish physicians’ interest in billing reimbursable codes. Ironically, the value of smoking cessation in value-based settings is even greater than in fee-for-service settings. Studies that can easily be completed on EMR systems can document the magnitude of the opportunity in your practice or health system.
Part of the problem is that most electronic health records (EHR) do not capture conversations documented in free text. A physician may indeed provide brief counseling on every visit, but there is no evidence that the conversation took place. Any conversation about tobacco use that exceeds three minutes can be reimbursed using CPT 99406. The clearest example of missed opportunities to bill comes from prescribing medications for smoking cessation. Instructions on how to use the medication in the context of a comprehensive plan for quitting would certainly take more than three minutes, yet most prescribing events are not associated with counseling codes. A simple adjustment to the EHR setup, with the installation of a quick button linked to the CPT code, would help bridge the gap between the clinical event and reimbursement.
CMS guidelines, which have been adopted by almost all health plans, support reimbursement of up to eight sessions per calendar year. (Detailed coding and billing requirements are available.) Counseling can be provided by any staff under the doctor’s supervision who have received training. This includes nurses, pharmacists, social workers, medical assistants, and office staff. On any occasion when the conversation about tobacco exceeds three minutes, a properly documented note can support reimbursement. Some scenarios other than prescribing medication that can support reimbursement are:
- Referral to the state quitline at 1-800-QUIT-NOW
- Follow-up visits for prevention of relapses
- Counseling regarding medical risks of continued smoking for patients not ready to quit
- Motivational interviewing for patients not ready to quit
- Identification of financial cost of smoking to further motivate a quit attempt
- Discussion of vaping as an approach to smoking cessation
- Discussion of use of ZYN as a modified risk tobacco product
- General discussion of tobacco harm reduction
- Conversations with current smokers about lung cancer screening
Discussion of tobacco harm reduction is a new and rapidly emerging domain which has been shaped by the rapid adoption of electronic cigarettes. Over six million smokers have switched from cigarettes to vaping, and a work group from the Society for Research on Nicotine and Tobacco has published recommendations regarding the use of e-cigarettes in smoking cessation. A new choice architecture for people who smoke cigarettes is emerging and will facilitate conversations about cessation and harm reduction that have been delayed or deferred in the past.
There are other reasons to capture tobacco treatment with coding and billing. Quality assurance programs regarding tobacco treatment will under-report your performance. This is especially important with the new National Committee for Quality Assurance (NCQA) HEDIS measure on Tobacco Use Screening and Intervention. Billing and coding of treatment also serves as a reminder to update tobacco use status regularly and identify current and former smokers for lung cancer screening.
Some may argue that the current Medicare reimbursement rate for CPT 99406, which is about $15.50, is not sufficient, but I invite you to use the XL worksheet attached to do the math on the number of visits per year you have in your practice. Bear in mind that the service can be performed by anyone in a white coat. This is one of the few true alignments of good medicine and good business practice.
Tobacco-related diseases represent a major cause of death, disability, and medical cost, and we have effective treatments and tactics for harm reduction. The data currently available shows that we could perform better, thereby improving patient outcomes and the economic performance of our practices. For additional information on how to organize your practice for better performance, visit my website.
Edward Anselm is a board-certified internist with a long-standing focus on public health, tobacco control, and preventive care. He earned his medical degree from the Chicago Medical School at Rosalind Franklin University and completed his internal medicine residency at Montefiore Medical Center in New York. Over the past three decades, Dr. Anselm has served in senior leadership roles across clinical, corporate, and managed-care settings, including chief medical officer positions at HIP Health Plan of New York, FidelisCare, and Health Republic Insurance of New York.
Recently retired from his role as medical director at Aetna, Dr. Anselm continues to teach at the Icahn School of Medicine at Mount Sinai as a clinical assistant professor. His current work focuses on strengthening reimbursement pathways for tobacco cessation and preventive services, helping clinicians integrate evidence-based care that improves patient outcomes while supporting practice sustainability. His research has been published in the American Journal of Accountable Care, the American Journal of Preventive Medicine, AJPM Focus, and Health Affairs Forefront, including articles on tobacco control in accountable care, underbilling of cessation services, and the financial and quality benefits of treating tobacco use as a clinical priority.
Dr. Anselm’s educational and policy work is shared through EdwardAnselmMD.com and The Anselm Nicotine Prescription, with professional updates available on LinkedIn.
