Currentpriority healthPolicy No. 128

SMOKING CESSATION

This billing policy governs Priority Health reimbursement and documentation requirements for tobacco/smoking cessation counseling services for Commercial, Medicare, and Medicaid lines of business; it affects providers submitting claims for these services.

Policy Summary

Payerpriority health

PolicySmoking Cessation — Billing/Reimbursement

Policy CodePolicy No. 128

Change TypeNo material changes

Effective DateDate of origin: Aug. 2025

Next Review Date

Key ActionObtain a Pre-Service Organization Determination (PSOD) for Medicare indications that do not meet NCD/LCD/policy; authorization may be required based on setting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 8max sessions/year

2attempts/year

99406/99407key CPT codes

4000F/4001F/4004FCPT II (report-only)

Coverage Criteria for Smoking Cessation Counseling

Coverage criteria for smoking cessation counseling

Covered when ALL of the following are met:

ALL of the following

CPT codes 99406 (intermediate, >3 minutes up to 10 minutes) and 99407 (intensive, >10 minutes) are payable as a preventive benefit; when applicable there is no member copayment or deductible
CPT II codes 4000F, 4001F, and 4004F are report-only (CPT II) and are not separately reimbursed
Providers must document the exact time spent with the patient and what was discussed during the smoking cessation counseling session; documentation must support the code billed; vague time statements (examples provided in policy) are inadequate
Codes must be billed with the appropriate ICD-10 code identifying tobacco use

Policy Summary

Payerpriority health

PolicySmoking Cessation — Billing/Reimbursement

Policy CodePolicy No. 128

Change TypeNo material changes

Effective DateDate of origin: Aug. 2025

Next Review Date

Key ActionObtain a Pre-Service Organization Determination (PSOD) for Medicare indications that do not meet NCD/LCD/policy; authorization may be required based on setting.

SourceLink

On This Page

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Apply modifiers per CMS/NCCI and Priority Health guidance only when supported by documentation (examples: 93 or 95 for telehealth POS 02 or 10; 33 when reported as a preventive service; 25 when billed same day as an E/M)

Services will be considered when furnished in an appropriate setting to the patient's medical needs and condition; authorization may be required based on setting or payer-specific rules

Frequency limits: Individuals are allowed up to two tobacco cessation counseling attempts annually; each attempt may include up to four sessions, for a maximum of up to eight billable sessions per individual per year

Documentation examples

Adequate: document exact minutes and content of counseling (plans to decrease smoking and/or steps to quit)
Inadequate examples: statements such as 'Spent greater than 3 minutes counseling the patient on smoking,' 'Spent between 3 to 10 minutes counseling the patient on smoking,' or 'Spent over 10 minutes counseling the patient on smoking' do not meet documentation requirements

Billing expectations

Bill CPT 99406 or 99407 with appropriate ICD-10 tobacco-use diagnosis code
Report CPT II codes 4000F, 4001F, 4004F as required (report-only); these CPT II codes do not generate separate reimbursement

Authorization/Pre-service

For Medicare indications that do not meet an NCD, local LCD, or specific medical policy, a Pre-Service Organization Determination (PSOD) is required; authorization may be required based on setting

Modifier guidance

Use modifiers per Priority Health/CMS NCCI guidance and only when supported by documentation (e.g., 93/95 for telehealth POS 02 or 10; 33 for preventive service reporting; 25 when billed same day as an E/M)

Frequency limits

Maximum 8 sessions per individual per year — up to 2 cessation attempts annually, with up to 4 sessions allowed per attempt

Place of service

Coverage considered when services are furnished in the appropriate setting to the patient's medical needs and condition; providers should verify if authorization is required for the place of service

Provider responsibility

Complete and thorough documentation to substantiate the procedure performed is the responsibility of the provider; consult any additional applicable documentation guidelines

Supportive coding note

Follow Priority Health billing and coding guidelines (CMS NCCI) when applying modifiers; incorrect application may result in denials

Preventive benefit statement

When applicable, smoking cessation counseling (CPT 99406/99407) is payable as a preventive benefit with no member copayment or deductible

Report-only codes

CPT II codes 4000F, 4001F, and 4004F are CMS CPT II report-only codes and have no separate reimbursement

Coding requirement

Codes should be billed with the appropriate ICD-10 code identifying tobacco use

Documentation inadequacy examples

Examples of inadequate documentation lack exact time and content detail and therefore do not support the billed code

Denial risk

Incorrect application of modifiers or inadequate documentation may result in claim denials

Operational note

Providers should reference the Priority Health provider manual for full modifier guidance and any setting-specific authorization requirements

Summary

Counseling is covered with documentation that specifies time and content, billed with appropriate ICD-10, subject to frequency limits, modifier rules, and place-of-service/authorization requirements

References

Policy details: reimbursement specifics, documentation requirements, modifiers, frequency, and place of service as outlined in Priority Health policy

CPT and CPT II Codes for Tobacco Cessation

Smoking cessation counseling and CPT II codesCPTCovered

99406	Smoking and tobacco use cessation counseling visit; intermediate, >3 minutes up to 10 minutes
99407	Smoking and tobacco use cessation counseling visit; intensive, >10 minutes
4000F	Tobacco use cessation intervention, counseling (CPT II) - report only
4001F	Tobacco use cessation intervention, pharmacologic therapy (CPT II) - report only
4004F	Patient screened for tobacco use and received tobacco cessation intervention (CPT II) - report only

Annual session limit — inv-03: Maximum sessions and attempts

Maximum annual sessionsUp to 8 billable tobacco cessation counseling sessions per individual per year

Attempts per yearUp to 2 cessation counseling attempts annually

Sessions per attemptUp to 4 intermediate or intensive sessions per attempt

Applicable CPT codesCPT 99406 and 99407 used to bill these sessions

Pre-Service Determination and Authorization Guidance

Prior Authorization

Pre‑service determination (PSOD) and possible authorization

For Medicare members when the indication does not meet an NCD, local LCD, or specific medical policy, the provider must complete a Pre‑Service Organization Determination (PSOD) before furnishing the service. Additionally, coverage will be considered only when services are furnished in an appropriate setting to the patient’s needs, and authorization may be required based on place of service.

Complete a Pre‑Service Organization Determination (PSOD) for Medicare indications not meeting NCD/LCD/specific policy.
Confirm appropriate place of service; obtain authorization when required by setting.

Reimbursement and Scope Definitions

Reimbursement for tobacco cessation counseling — inv-05: Policy scope

Scope of reimbursementPriority Health reimburses fee‑for‑service for tobacco cessation counseling codes

Eligible providersReimbursement available to primary care and specialty physicians

Program linesPolicy governs reimbursement and documentation requirements for Commercial, Medicare, and Medicaid lines of business