Documentation, Diagnosis and Billing in Behavioral Health Settings

Coverage of tobacco cessation treatment (or tobacco dependency treatment) is needed to be able to bill the insurance plan (also called the payor) for these services. Additionally, it is important to understand which types of providers are able to bill for theses services, even if a treatment is covered. There is extensive information on how to assess coverage of these treatments in your state, that you can find on the Lung Association website.

Most insurance plans are required to cover at least some tobacco cessation treatment, however payors can impose barriers to access that care, such as limiting the number of refills a patient can get per year or requiring prior authorization. It is important to understand these requirements, as they may result in the provider not being reimbursed. Understanding coverage can be complicated, but there are many tools and resources to help.

Some key questions to behavioral health providers: 

• What types of insurance coverage do your patients have? 
• Are you currently billing for tobacco screening, cessation counseling, and treatment services? 
• If the provider answers “Yes”:
  • What codes are being used? Are you being reimbursed? Are claims being denied?

Visit Lung.org/CessationTA  for additional information and resources on tobacco treatment coverage

The current set of diagnostic codes used in the United States are the ICD-10-CM codes. They were developed based on the World Health Organization’s (WHO) ICD-10 codes. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)developed a new Procedure Coding System (ICD-10-PCS) for inpatient procedures. These codes are an important part of the billing process.

The assignment of proper diagnostic codes is required to successfully bill for tobacco treatment services. For example, the F17 code series are used when providing tobacco treatment to a person who has a nicotine dependence. F17 is a code in the 10th revision of the International Statistical Classification of Diseases and Related Health problems (ICD-10). The code is used to indicate a person’s dependence on nicotine. This indication of nicotine dependence is what establishes medical necessity for the tobacco treatment service being provided. Medical necessity allows providers to bill for the service. See the Diagnosis Coding Guide on page 7 of the American Lung Association Billing Guide for additional information.

ICD-10 codes are the cornerstone of classifying diseases, injuries, health encounters and inpatient procedures in healthcare settings. U.S. public health officials at the federal, state, and local level rely on the receipt of ICD-10 coded data from healthcare providers to conduct many disease-related activities. The Centers for Disease Control and Prevention (CDC) programs use the ICD-10 codes to conduct surveillance (e.g., chronic disease and injury surveillance, health care utilization, health care-associated adverse events), for case findings lists to identify cases of reportable cancers and certain birth defects and disabilities, and to provide public use data files for public analysis.

A primary user of ICD codes includes health care personnel, such as physicians and nurses, as well as medical coders, who assign ICD-10 codes to verbatim or abstracted diagnosis or procedure information, and thus are originators of the ICD-10 codes. The codes are used for a variety of purposes, including statistics, billing and claims reimbursement.

A secondary user of ICD-10 codes is someone who uses already coded data from hospitals, health care providers, or health plans to conduct surveillance and/or research activities. Public health is largely a secondary user of ICD-10 coded data.

Regardless of the payor (e.g., Medicare, Medicaid, private insurance), providers need to use ICD-10 codes and provide documentation regarding medical necessity and the specifics of what was provided. The goal is to clearly establish medical necessity and ensure payment for services. Diagnosis Coding alone is not sufficient.

Medicare and other payors find improper payments by selecting a sample of claims or flagging suspicious claims and requesting medical documentation from the provider. The claim is reviewed against the provider’s medical documentation – either an electronic medical record or paper record.

As such, the following items should be documented in the medical record:

• The patient/client’s willingness to attempt to quit
• What was discussed during counseling/treatment planning
• Amount of time spent counseling the patient/client
• Tobacco use   
• Advice to quit and impact of smoking provided to patient
• Methods and skills suggested to support cessation
• Medication management
• Setting a quit date with the patient
• Follow-up arranged
• Resources made available to the patient

The Lung Association’s Billing Guide Addendum for Behavioral Health has additional information on documentation requirements, including tips for behavioral health providers. 

A fundamental decision that influences how a provider codes is whether tobacco treatment services constitute counseling that merits a separate code or will be included in a time-based Evaluation and Management (E/M) service code (which could be considered a “typical” provider visit). An additional decision is whether the tobacco service should be considered an “incident to” service; these are services that are important for achieving a desired outcome but “incidental” to the services initially provided by the provider.  

Below is a table of recommended resources with clickable links for more information on billing codes: