LCD/NCD Portal

NCD210.4.1

 

COUNSELING TO PREVENT TOBACCO USE

 

Effective Date of this Version

1/3/2011

 

Benefit Category

• Additional Preventive Services.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

 

General

• Tobacco use remains the leading cause of preventable morbidity and mortality in the U.S. and is a major contributor to the nation’s increasing medical costs.

o Despite the growing list of adverse health effects associated with smoking, more than 45 million U.S. adults continue to smoke and approximately 1,200 die prematurely each day from tobacco-related diseases.

o Annual smoking-attributable expenditures can be measured both in direct medical costs ($96 billion) and in lost productivity ($97 billion), but the results of national surveys have raised concerns that recent declines in smoking prevalence among U.S. adults may have come to an end.

o According to the U.S. Department of Health and Human Services (DHHS) Public Health Service (PHS) Clinical Practice Guideline on Treating Tobacco Use and Dependence (2008), 4.5 million adults over 65 years of age smoke cigarettes.

o Even smokers over age 65, however, can benefit greatly from abstinence, and older smokers who quit can reduce their risk of death from coronary heart disease, chronic obstructive lung disease and lung cancer, as well as decrease their risk of osteoporosis.

• Medicare Part B (section 210.4 of the National Coverage Determination (NCD) Manual) already covers cessation counseling for individuals who use tobacco and have been diagnosed with a recognized tobacco-related disease or who exhibit symptoms consistent with tobacco-related disease.

o In November 2009, based upon authority to cover “additional preventive services” for Medicare beneficiaries if certain statutory requirements are met, the Centers for Medicare & Medicaid Services (CMS) initiated a new national coverage analysis to evaluate whether the existing evidence on counseling to prevent tobacco use is sufficient to extend national coverage for cessation counseling to those individuals who use tobacco but do not have signs or symptoms of tobacco-related disease.

o One of these statutory requirements is that the service be categorized as a grade A (strongly recommends) or grade B (recommends) rating by the US Preventive Services Task Force (USPSTF).

 

Indications and Limitations of Coverage

 

Nationally Covered Indications

• Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries

o Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;

o Who are competent and alert at the time that counseling is provided; and,

o Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

• Intermediate and intensive smoking cessation counseling services will be covered under Medicare Part B when the above conditions of coverage are met, subject to frequency and other limitations.

o That is, similar to existing tobacco cessation counseling for symptomatic individuals, CMS will allow 2 individual tobacco cessation counseling attempts per 12-month period.

o Each attempt may include a maximum of

 4 intermediate OR intensive sessions.

 With a total benefit covering up to 8 sessions.

 Per 12-month period per Medicare beneficiary who uses tobacco.

o The practitioner and patient have the flexibility to choose between intermediate (more than 3 minutes but less than 10 minutes), or intensive (more than 10 minutes) cessation counseling sessions for each attempt.

 

Nationally Non-Covered Indications

• Inpatient hospital stays with the principal diagnosis of tobacco use disorder are NOT reasonable and necessary for the effective delivery of tobacco cessation counseling services.

• Therefore, we will NOT cover tobacco cessation services if tobacco cessation is the primary reason for the patient’s hospital stay.

 

Other

• Section 4104 of the Affordable Care Act provided for a waiver of the Medicare coinsurance and Part B deductible requirements for this service effective on or after January 1, 2011.

• Until that time, this service will continue to be subject to the standard Medicare coinsurance and Part B deductible requirements.

• (This NCD last reviewed August 2010.)

 

Claims Processing Instructions

• TN 2058 (Medicare Claims Processing)

 

Coverage Transmittal Link

• http://www.cms.gov/transmittals/downloads/R126NCD.pdf

 

National Coverage Analyses (NCAs)

• This NCD has been or is currently being reviewed under the National Coverage Determination process.

• The following are existing associations with NCAs, from the National Coverage Analyses database.

• Original consideration for Counseling to Prevent Tobacco Use (CAG-00420N) opens in new window

 

Medicare NCD Link