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    v1.0.30
    OpenPayerPolicy UpdatesObstetrics/GynecologyLouisiana Medicaid Tobacco Policy Update | OpenPay…
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    CurrentLouisiana Department of HealthPolicy 20-14

    Tobacco Cessation for Pregnant Women

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    This policy governs Louisiana Medicaid coverage of tobacco cessation counseling and pharmacotherapy for pregnant beneficiaries, including eligible service periods, counseling limits, documentation requirements, billing rules, and coordination requirements.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyTobacco Cessation for Pregnant Women
    Policy CodePolicy 20-14
    Change TypeNo material clinical or coverage changes
    Effective DateDecember 1, 2020
    Next Review DateN/A
    Key ActionDocument the beneficiary's pregnancy or postpartum status and estimated due date or date of delivery.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    60 daysPostpartum coverage period
    4Sessions per quit attempt
    2Quit attempts per year
    8Sessions per year

    Covered Services and Limits

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    Covered eligibility and service delivery

    Covered when all applicable service and provider conditions are met.

    Eligibility and service delivery

    • Covered service: The service is tobacco cessation counseling or pharmacotherapy provided to a pregnant beneficiary.
    • Covered counseling encounter: The counseling is provided during the prenatal period through 60 days postpartum.
    Qualified counseling delivery: Counseling is provided face-to-face by the beneficiary's primary care provider or obstetrical provider; alternatively, another appropriate healthcare professional provides it upon referral from the primary care or obstetrical provider with coordinated care.

    Counseling frequency and medical necessity exception

    Standard limits apply unless medical necessity supports exceeding them.

    Counseling limits

    • Per-attempt limit: No more than four tobacco cessation counseling sessions are provided per quit attempt.up to 4 sessions per quit attempt
    • Annual attempt limit: No more than two quit attempts are provided per calendar year.up to 2 quit attempts per calendar year
    • Annual session limit: No more than eight counseling sessions are provided per calendar year.up to 8 sessions per calendar year
    Limit exception: The standard limits are not exceeded; or the limits are exceeded because the services are deemed medically necessary and the claim is submitted hardcopy with supporting documentation.

    Required session documentation and billing

    Each counseling session must satisfy the documentation and billing conditions.

    Session documentation and billing

    • Clinical status: The record documents pregnancy or postpartum status and the estimated due date or date of delivery.
    • Counseling intervention: The record documents tobacco-use assessment, cessation advice, readiness assessment, quit-date planning, cessation methods and skills, and follow-up counseling arrangements.
    • Distinct service: The record verifies the counseling intervention and supports a significant and separately identifiable service for the session.
    • Time: The record includes the amount of time spent with the patient for the time-based CPT service.

    Billing and Coding Requirements

    Required prenatal counseling modifierModifier
    -THRequired when billing for tobacco cessation counseling within the prenatal period; not used for postpartum services.

    Documentation and Claims Guidance

    Documentation Required

    Pregnancy or Postpartum Status

    Document the beneficiary’s pregnancy or postpartum status in the health record, including the estimated due date or date of delivery. Claims must also reflect pregnancy or the 60-day postpartum period and a tobacco/nicotine use disorder.

    • Record pregnancy or postpartum status.
    • Include the estimated due date or date of delivery.
    • Use diagnosis codes reflecting pregnancy or the 60-day postpartum period and tobacco/nicotine use disorder.
    Documentation Required

    Required Counseling Elements

    Document the required tobacco-cessation counseling intervention for each session. At a minimum, the record must show that the beneficiary was asked about tobacco use, educated about the impact of smoking and advised to quit, assessed for willingness to quit, assisted with setting a quit date and developing quitting methods and skills, and scheduled for follow-up counseling.

    • Ask about tobacco use.
    • Explain the impact of smoking and advise the beneficiary to quit.
    • Assess willingness to attempt to quit.
    • Assist with setting a quit date.
    • Provide methods and skills to assist with the quit attempt.
    • Arrange follow-up counseling.
    Documentation Required

    Verify Each Counseling Service

    Verify the counseling intervention in the beneficiary’s record and document that each counseling session was a significant and separately identifiable service. When counseling is provided on the same day as an evaluation and management visit, clinical documentation must support any applicable separate-service modifier.

    • Verify the counseling intervention.
    • Show a significant and separately identifiable service for each session.
    • Support any applicable separate-service modifier with clinical documentation when counseling and an evaluation and management visit occur on the same day.
    Billing Rule

    Document Counseling Time

    Because tobacco-cessation counseling CPT codes are time-based, document the amount of time spent with the patient for each counseling service.

    • Record the time spent providing counseling to the patient.
    Prior Authorization

    Exception to Service Limits

    Services exceeding the annual session or quit-attempt limits require a hardcopy claim with supporting documentation. The documentation must detail the beneficiary’s failed attempts to stop using tobacco products and confirm that she still desires to quit.

    • Submit claims exceeding the limits hardcopy.
    • Document failed attempts to stop using tobacco products.
    • Document that the beneficiary still desires to quit.
    Denial Risk

    Exceeding Limits Without Documentation

    Claims for counseling beyond the covered limits may be denied when the required exception documentation is not submitted. The standard limits are up to four sessions per quit attempt, up to two quit attempts per calendar year, and a maximum of eight counseling sessions per calendar year.

    • Four counseling sessions per quit attempt.
    • Two quit attempts per calendar year.
    • Eight counseling sessions per calendar year.
    • Services beyond these limits require the hardcopy claim and supporting documentation described above.
    Denial Risk

    Complete Clinical Documentation

    Missing clinical or service documentation creates a denial risk. The record must establish the applicable pregnancy or postpartum coverage condition, tobacco/nicotine use disorder, required counseling elements, counseling intervention verification, time spent, and a significant and separately identifiable service for each session.

    • Document pregnancy or postpartum status and the estimated due date or delivery date.
    • Use diagnosis codes supporting pregnancy or the 60-day postpartum period and tobacco/nicotine use disorder.
    • Document the required counseling activities and follow-up.
    • Document intervention verification, time spent, and the separately identifiable service.
    Billing Rule

    Use the Prenatal Modifier Correctly

    Use the -TH modifier when billing tobacco-cessation counseling provided during the prenatal period. Do not use the -TH modifier for services provided during the postpartum period.

    • Prenatal counseling: -TH modifier required.
    • Postpartum counseling: -TH modifier prohibited.

    Policy Background

    Louisiana Medicaid covers tobacco cessation counseling and pharmacotherapy as extended services for pregnant women for dates of service on or after December 1, 2020. Counseling is available during the prenatal period through 60 days postpartum and is intended to assess tobacco use, support quit planning, provide cessation methods and skills, and arrange follow-up counseling.

    Coverage Definitions

    Prenatal through postpartum coverage period
    DefinitionThe period beginning during pregnancy and continuing through 60 days after delivery.
    Covered servicesTobacco cessation counseling and pharmacotherapy are covered during this period for pregnant beneficiaries.
    Quit attempt
    DefinitionA beneficiary's effort to stop using tobacco products.
    Sessions allowed per attemptUp to four tobacco cessation counseling sessions per quit attempt.
    Annual limitUp to two quit attempts per calendar year, with a maximum of eight counseling sessions per calendar year.
    Policy Summary
    PayerLouisiana Department of Health
    PolicyTobacco Cessation for Pregnant Women
    Policy CodePolicy 20-14
    Change TypeNo material clinical or coverage changes
    Effective DateDecember 1, 2020
    Next Review DateN/A
    Key ActionDocument the beneficiary's pregnancy or postpartum status and estimated due date or date of delivery.
    SourceLink
    On This Page
    Covered Services and LimitsBilling and Coding RequirementsDocumentation and Claims GuidancePolicy BackgroundCoverage Definitions
    medical necessity exception

    Supporting documentation must detail failed attempts to stop using tobacco products and the beneficiary's continued desire to quit.

  1. Diagnosis coding: Claim diagnosis codes reflect that the beneficiary is pregnant or within the 60-day postpartum period and has a tobacco or nicotine use disorder.