08/26/14
Informational Notice
To: Enrolled Physicians; Advanced Practices Nurses (APNs); Federally Qualified Health Centers (FQHCs); Rural Health Clinics (RHCs); Encounter Rate Clinics (ERCs); Certified Health Departments; School-Based Clinics; and Pharmacies
Re: Tobacco Cessation Counseling Services and Pharmacotherapy for Pregnant and Post-Partum Women Age 21 and Over and Children through Age 20
Section 4107 of the Affordable Care Act (P.L. 111-148), amended Title XIX (Medicaid) of the Social Security Act to provide for Medicaid coverage of comprehensive tobacco cessation services for pregnant and up to 60-day post-partum women age 21 and over, including both counseling and pharmacotherapy, without cost sharing.
The Illinois Department of Healthcare and Family Services (HFS) has filed administrative rules to formalize coverage of tobacco cessation counseling services and pharmacotherapy for pregnant and up to 60-day postpartum women. While children through age 20 have been eligible to receive tobacco cessation services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit, these counseling procedures and pharmacotherapy also apply to this population.
Counseling Procedure Codes
Effective with dates of service on and after January 1, 2014, tobacco cessation counseling services for the above populations may be a separately billable service under the following procedure codes:
99406 – Smoking and Tobacco Use Cessation Counseling Visit; Intermediate, Greater than 3 Minutes Up to 10 Minutes
99407 – Smoking and Tobacco Use Cessation Counseling Visit; Intensive, Greater than 10 Minutes
Duration of Counseling
For pregnant and up to 60-day post-partum women age 21 and over, HFS will reimburse up to a maximum of three quit attempts per calendar year, with up to four individual face-to-face counseling sessions per quit attempt. The 12 maximum counseling sessions include any combination of the two procedure codes identified above. These counseling sessions must be provided by, or under the supervision of, a physician, or by any other health care professional who is legally authorized to furnish such services under State law, and who is authorized to provide Medicaid covered services other than tobacco cessation services.
In addition, the patient’s medical record must be properly documented with provider signature, and include the total time spent and what was discussed during the counseling session, including cessation techniques, resources available and follow-up.
Note: Children through age 20 are not restricted to the maximum twelve counseling sessions.
Pharmacotherapy
The department covers FDA-approved nicotine replacement therapy in multiple forms, as well as two prescription medications indicated for use as an aid to smoking cessation. Providers may refer to the department’s
Drug Prior Authorization webpage to determine specific drug coverage and prior approval requirements. Nicotine replacement duration of therapy is normally limited to three months in a year; however, duration limitations may be overridden by the department through the prior approval process on an individual patient basis. To request prior approval for a specific drug, please link to the
Drug Prior Approval Information webpage.
Please note, per U.S. Public Health Service published guidelines, pharmacotherapy for tobacco cessation is not recommended for pregnant women due to lack of evidence regarding its safety and effectiveness in pregnant women; however, its use may be evaluated on an individual basis by the woman and her physician.
Illinois Tobacco Quitline
HFS promotes smoking cessation with all participants, but is particularly interested in pregnant women and youth. HFS encourages all providers to take advantage of the resources available to address smoking cessation including information provided by the Illinois Department of Public Health at the
Illinois Tobacco Quitline website or by calling 1-866-QUIT-YES (1-866-784-8937).
Any questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.
Theresa Eagleson, Administrator
Division of Medical Programs
