Billing for Tobacco Cessation Services
This clarification is to reinforce the Department of Human Services (DHS) policy regarding billing for tobacco cessation services. In order to bill the department for tobacco cessation services provided to fee-for-service (FFS) Medical Assistance (MA) recipients (procedure code S9075) a provider must:
- Be pre-approved by the Department of Health (DOH) as a Tobacco Cessation Program (TCP).
- Be a licensed health care provider such as a physician, dentist, psychologist, certified registered nurse practitioner, or an independent medical/surgical clinic, general hospital, rehabilitation hospital, pharmacy, home health agency, rural health clinic/federally qualified health center, outpatient drug, and alcohol facility, outpatient psychiatric clinic, or family planning clinic.
- Enroll in the MA program, either under the provider's existing provider type or as a provider type 37 (tobacco cessation provider).
Enrolled MA providers may provide and bill DHS for tobacco cessation counseling services provided to FFS MA recipients if the provider is approved and included in the DOH Pre-Approved Tobacco Cessation Registry.
Providers are pre-approved by meeting the DOH standards for the Tobacco Cessation Provider Programs and completing the Pennsylvania DOH Pre-Approval Registry of TCP Application. A separate DOH Pennsylvania Pre-Approved Tobacco Cessation Registry Application must be completed for each county in which the TCP operates.
Providers are pre-approved by meeting the DOH standards for the TCP and completing the Pennsylvania DOH Pre-Approval Registry of TCP Application. A separate DOH Pennsylvania Pre-Approved Tobacco Cessation Registry Application must be completed for each county in which the TCP operates.
The Pennsylvania Pre-Approved Tobacco Cessation Registry Application request form can be found on the DOH website.
In order to bill the MA fee-for-service, healthcare professionals or healthcare-related entities with expertise in tobacco cessation, pre-approved by the DOH as a TCP, must enroll in the MA program as either an existing provider type, if appropriate, or as a provider type 37, tobacco cessation provider.
MA Providers please note: On the bottom of the first page of the "DOH Pennsylvania Pre-approved Tobacco Cessation Registry Application" is the following:
If the MA provider checks the first "Yes" box, DOH will automatically send your program information to the Office of Medical Assistance Programs (OMAP). When OMAP receives the DOH pre-approval letter, OMAP will generate a provider notification information form that indicates the provider may bill for tobacco cessation counseling. This is only true if the provider is already enrolled in MA. If not enrolled in MA the provider will need to enroll by completing and submitting an MA provider application that can be obtained on the Enrollment Page.
If the MA provider fails to check the "Yes" box, the MA provider is responsible to see that OMAP receives a copy of the DOH pre-approval letter to be placed in the MA provider's enrollment file. If OMAP does not receive a copy of the DOH pre-approval letter from either the DOH or MA provider, the MA provider will be unable to bill the MA FFS program for tobacco cessation counseling services.
Those health care professionals or health care-related entities approved as a TCP and enrolled in the MA program may bill DHS for tobacco cessation counseling (procedure code S9075) provided to FFS MA recipients. DHS defines one unit of a tobacco cessation counseling session as a 15-minute face-to-face encounter, for a maximum of 70 units per individual, per calendar year. Providers must provide a full 15-minute counseling session in order to submit a claim for one unit of service. Providers are not permitted to round the unit of service to the next higher unit when providing a partial unit of time or combine partial time units to equal a full unit of service.
MA Bulletin 99-04-11 titled "Coverage of Tobacco Cessation Drug Products and Counseling Services" issued and effective September 15, 2004, addressed the changes in policy to permit unlimited drug therapy regimens for tobacco cessation products per recipient per calendar year. NOTE: The recipient must be eligible for the pharmacy benefit under MA to be eligible for the pharmacy component of tobacco cessation. Additionally, this MA Bulletin addressed the changes in policy that permit a provider to bill a medical or office visit and a tobacco cessation counseling session on the same day for the same recipient, as well as increasing the number of tobacco cessation counseling sessions to 70 per calendar year, as described above. It is the department's objective that these changes will encourage increased availability of and use of tobacco cessation services.
MA Providers enrolled in the Healthy Beginnings Plus (HBP) Program may continue to provide, bill and receive payment for smoking cessation counseling to their prenatal care recipients in accordance with HBP requirements. HBP providers may not bill for tobacco cessation counseling in lieu of, or in conjunction with, HBP smoking cessation counseling.
Additional Note: Under DHS' HealthChoices Managed Care delivery systems, TCP providers are to enroll in their respective Physical Health or the Behavior Health Managed Care Organizations (MCO) for payment for tobacco cessation counseling services. Both the Physical Health MCO and Behavioral Health Primary Contractor/BH-MCO have the responsibility to ensure access to tobacco cessation counseling services. The Physical Health MCO has additional responsibility for ensuring access to tobacco cessation drugs. Both the Physical Health MCO and Behavioral Health Primary Contractor/BH-MCO are to ensure that their TCP provider network is sufficient to meet the needs of the MCO's members.