S4995 Smoking Cessation Gum HCPCS Reimbursement | OpenPayer

Summary & Overview

HCPCS Level II S4995: Smoking Cessation Gum

HCPCS Level II code S4995 designates smoking cessation gum used as a nicotine replacement therapy to support patients attempting to quit tobacco. Nationally, pharmacologic smoking cessation aids are a key component of tobacco dependence treatment and are commonly covered by commercial insurers and public payers due to their role in reducing smoking-related morbidity and long-term healthcare costs. This summary covers coverage and billing considerations for major payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find an overview of what S4995 represents clinically, typical sites of service such as retail pharmacy and outpatient clinics, and the payer landscape relevant to this HCPCS Level II code. The publication includes benchmarks for coverage and reimbursement practices, common billing modifiers and administrative notes, and the clinical context for when nicotine replacement gum is used. Information not provided in the input (such as associated taxonomies or ICD-10 pairings) is identified as unavailable. This national-level review is intended to help payers, billing professionals, and policy analysts understand the administrative and clinical framing of S4995 without offering clinical guidance.

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Billing Code Overview

HCPCS Level II code S4995 represents smoking cessation gum intended to assist patients in tobacco cessation. The service type is nicotine replacement therapy delivered as a pharmacologic aid for smoking cessation. The typical site of service is retail pharmacy or outpatient clinic where over‑the‑counter or dispensed smoking cessation products are provided to patients.

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 43-year-old patient presents to a primary care clinic seeking assistance to quit tobacco use. The clinician documents tobacco dependence and discusses pharmacologic and behavioral options. As part of a comprehensive smoking cessation plan, the clinician prescribes nicotine replacement therapy in the form of smoking cessation gum coded as S4995. The gum is dispensed or provided at the office or prescribed for pharmacy pickup. Typical workflow: tobacco use screening documented in the electronic medical record; counseling for cessation provided during the visit; prescription or in-office dispensing of S4995 with quantity and directions recorded; linkage to follow-up counseling or community resources; billing submitted by the clinic or durable medical supplier using S4995 with an appropriate modifier when applicable. Typical site of service: outpatient clinic, primary care office, community health center, or outpatient behavioral health setting. Typical patient scenario includes documentation of tobacco dependence, readiness to quit, and a care plan that includes nicotine replacement therapy with gum for short-term use and follow-up visits scheduled for medication efficacy and cessation counseling assessment.

Coding Specifications

Modifier	Description	When to Use
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Related Codes

HCPCS-S5571-INSULIN-DISPOSABLE-PEN-3ML

HCPCS S5571: Insulin Delivery Device, Disposable Pen, 3 ml Size

HCPCS-S0012-BUTORPHANOL-NASAL-SPRAY-25MG

HCPCS S0012: Butorphanol Tartrate Nasal Spray, 25 mg

HCPCS-S2115-PERIACETABULAR-OSTEOTOMY-INTERNAL-FIXATION

HCPCS S2115: Periacetabular Osteotomy with Internal Fixation

HCPCS-S5001-PRESCRIPTION-DRUG-BRAND-NAME

HCPCS Level II S5001: Prescription Drug, Brand Name

HCPCS-S5012-5PCT-DEXTROSE-POTASSIUM-CHLORIDE-1000ML

HCPCS Level II S5012: 5% Dextrose with Potassium Chloride, 1000 ml

HCPCS-S0353-CANCER-TREATMENT-PLANNING-CARE-COORDINATION-INITIAL

HCPCS Level II S0353: Cancer Treatment Planning and Care Coordination

HCPCS-LEVEL-II-S4017-INCOMPLETE-ART-CYCLE-CANCELLED-PRIOR-TO-STIMULATION

HCPCS Level II S4017: Incomplete ART Cycle, Cancelled Prior to Stimulation

HCPCS-S9484-CRISIS-INTERVENTION-MENTAL-HEALTH-PER-HOUR

HCPCS S9484: Crisis Intervention Mental Health Services, Per Hour

HCPCS-S5550-INSULIN-RAPID-ONSET-5-UNITS

HCPCS S5550: Insulin, Rapid-Onset, 5 Units

HCPCS-S8426-GRADIENT-PRESSURE-GLOVE-CUSTOM-HEAVY-WEIGHT

HCPCS S8426: Gradient Pressure Glove, Custom Made, Heavy Weight

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Taxonomy Code	Specialty	Notes
`207Q00000X`	Family Medicine	Primary care clinicians who commonly prescribe or dispense nicotine replacement gum.
`208D00000X`	General Practice	General practitioners managing tobacco cessation and providing `S4995`.
`208000000X`	Internal Medicine	Internists who counsel on and prescribe nicotine replacement therapy.
`3336C0003X`	Substance Use Disorders	Clinicians specializing in tobacco dependence treatment and behavioral interventions.
`363A00000X`	Nurse Practitioner	Advanced practice clinicians who often provide counseling and prescribe nicotine replacement products.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`F17.210`	Nicotine dependence, cigarettes, uncomplicated	Common primary diagnosis supporting nicotine replacement therapy with `S4995`.
`F17.211`	Nicotine dependence, cigarettes, in remission	May be used when documenting recent remission and need for relapse prevention with gum.
`F17.220`	Nicotine dependence, chewing tobacco, uncomplicated	Relevant when dependence on smokeless tobacco is addressed and nicotine gum is considered.
`Z71.6`	Tobacco abuse counseling	Captures counseling services provided alongside dispensing nicotine gum.
`Z72.0`	Tobacco use (habitual)	General code documenting current tobacco use supporting treatment with `S4995`.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99406`	Tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Commonly billed during the same encounter when brief counseling accompanies provision of nicotine gum.
`99407`	Tobacco use cessation counseling, intensive, greater than 10 minutes	Billed when intensive counseling is provided in conjunction with dispensing `S4995`.
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Often the visit level used when tobacco cessation counseling and prescription/dispensing of gum occur during a routine follow-up.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used for longer visits with added complexity, counseling, and medication management including `S4995`.
`99401`	Preventive medicine counseling (deprecated in some payers; use appropriate prevention coding)	Occasionally used for preventive counseling visits focused on smoking cessation depending on payer policy.