(Medicare Claims Processing Manual)

Deductible and coinsurance apply for services performed on August 25, 2010, through December 31, 2010. For claims with dates of service on and after January 1, 2011, coinsurance and deductible do not apply for G0436 and G0437.  Effective September 30, 2016, HCPCS codes G0436 and G0437 are no longer valid. The services previously represented by G0436 and G0437 should be billed under existing CPT codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater  than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater 10 minutes) respectively   NOTE: Section 4104 of ACA provided for a waiver of Medicare coinsurance and Part B deductible for this service effective on or after 1/1/11. Copayment/coinsurance waived; Deductible waived for HCPCS G0436 & G0437 through 9/30/16, for CPT codes 99406 & 99407 effe ctive 10/1/16.  150.3 - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  When denying claims for counseling to prevent tobacco use services submitted without ICD -10-CM is applicable, one of the following diagnosis codes:    ICD-10 CM Code  Code Description  F17.210  Nicotine dependence, cigarettes, uncomplicated  F17.211  Nicotine dependence, cigarettes, in remission  F17.213  Nicotine dependence, cigarettes, with withdrawal  F17.218  Nicotine dependence, cigarettes, with other nicotine -induced disorders  F17.219  Nicotine dependence, cigarettes, with unspecified nicotine -induced disorders  F17.220  Nicotine dependence, chewing tobacco, uncomplicated  F17.221  Nicotine dependence, chewing tobacco, in remission  F17.223  Nicotine dependence, chewing tobacco, with withdrawal  F17.228  Nicotine dependence, chewing tobacco, with other nicotine -induced disorders  F17.229  Nicotine dependence, chewing tobacco, with unspecified nicotine -induced disorders  F17.290  Nicotine dependence, other tobacco product, uncomplicated  F17.291  Nicotine dependence, other tobacco product, in remission  F17.293  Nicotine dependence, other tobacco product, with withdrawal  F17.298  Nicotine dependence, other tobacco product, with other nicotine -induced disorders  F17.299  Nicotine dependence, other tobacco product, with unspecified nicotine -induced disorders  T65.211A  Toxic effect of chewing tobacco, accidental (unintentional), initial encounter  T65.212A  Toxic effect of chewing tobacco, intentional self -harm, initial encounter  T65.213A  Toxic effect of chewing tobacco, assault, initial encounter  T65.214A  Toxic effect of chewing tobacco, undetermined, initial encounter  T65.221A  Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter  T65.222A  Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter  T65.223A  Toxic effect of tobacco cigarettes, assault, initial encounter  T65.224A  Toxic effect of tobacco cigarettes, undetermined, initial encounter  T65.291A  Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter  T65.292A  Toxic effect of other tobacco and nicotine, intentional self -harm, initial encounter  T65.293A  Toxic effect of other tobacco and nicotine, assault, initial encounter  T65.294A  Toxic effect of other tobacco and nicotine, undetermined, initial encounter  Z87.891  Personal history of nicotine dependence    or without above ICD -10-CM is applicable Part A/B MACs (A), (B), or (HHH) shall use the following messages:   CARC 16  Claim/service lacks information or has submission/billing error(s).   RARC M64 -  Missing/incomplete/invalid other diagnosis   A/B MACs (A), (B), or (HHH) shall use Group Code CO, assigning financial liability to the provider, if a claim is received with no signed ABN on file.   MSN 15.4: The information provided does not support the need for this service or item.   MSN Spanish Version: La informacin proporcionada no confirma la necesidad para este servicio o artculo   When denying claims for counseling to prevent tobacco use services and smoking and tobacco- use cessation counseling services that exceed a combined total of 8 sessions within a 12- month period (99406, 99407), A/B MACs (A), (B), or (HHH) shall use the following messages:   CARC 119: Benefit maximum for this time period or occurrence has been reached.   RARC N362: The number of days or units of service exceeds our acceptable maximum.   A/B MACs (A), (B), or (HHH) shall use Group Code PR, assigning financial liability to the beneficiary, if a claim is received with a signed ABN on file.   A/B MACs (A), (B), or (HHH) shall use Group Code CO, assigning financial liability to the provider, if a claim is received with no signed ABN on file.   MSN 20.5: These services cannot be paid because your benefits are exhausted at this time.   MSN Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   150.4 - Common Working File (CWF)  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  The Common Working File (CWF) shall edit for the frequency of service limitations of counseling to prevent tobacco use sessions and smoking and tobacco- use cessation counseling services (99406, 99407) rendered to a beneficiary for a combined total of 8 sessions within a 12- month period. The beneficia ry may receive another 8 sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered counseling session was performed. To start the count for  the second or subsequent 12- month period, begin with the month after the month in which the first Medicare covered counseling session was performed and count until 11 full months have elapsed.   By entering the beneficiarys health insurance claim number (HICN), providers have the capability to view the number of sessions a beneficiary has received for this service via  inquiry through CWF.   160 - Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   For services furnished on or after November 8, 2011, the Centers for Medicare & Medicaid Services (CMS) covers intensive behavioral therapy (IBT) for cardiovascular disease (CVD).  See National Coverage Determinations (NCD) Manual (Pub. 100- 03) 210.11 for  complete coverage guidelines.   160.1 - Coding Requirements for IBT for CVD Furnished on or After November 8, 2011  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   The following is the applicable Healthcare Procedural Coding System (HCPCS) code for IBT for CVD:   G0446: Annual, face -to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes   A/B MACs (A) and (B) shall not apply deductibles or coinsurance to claim lines containing HCPCS code G0446.  160.2 - Claims Processing Requirements for IBT for CVD Furnished on or After November 8, 2011 (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   160.2.1 - Correct Place of Service (POS) Codes for IBT for CVD on Professional Claims  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   A/B MACs (B) shall pay for IBT CVD, G0446 only when services are provided at the following POS:   11- Physicians Office  22-Outpatient Hospital 49- Independent Clinic  72-Rural Health Clinic   Claims not submitted with one of the POS codes above will be denied.   The following messages shall be used when A/B MACs (B) deny professional claims for incorrect POS:   Claim Adjustment Reason Code (CARC) 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) , if present.   Remittance Advice Remark Code (RARC) N428:  Not covered when performed in this place of service.   Medicare Summary Notice (MSN) 21.25:  This service was denied because Medicare only covers this service in certain settings.   Spanish Version:  El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  160.2.2 - Provider Specialty Edits for IBT for CVD on Professional Claims  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   A/B MACs (B) shall pay claims for HCPCS code G0446 only when services are submitted by the following provider specialty types found on the providers enrollment record:   01= General Practice  08 = Family Practice  11= Internal Medicine  16 = Obstetrics/Gynecology 37= Pediatric Medicine  38 = Geriatric Medicine  42= Certified Nurse Midwife  50 = Nurse Practitioner  89 = Certified Clinical Nurse Specialist 97= Physician Assistant   A/B MACs (B) shall deny claim lines for HCPCS code G0446 performed by any other provider specialty type other than those listed above.  The following messages shall be used when A/B MACs (B) deny IBT for CVD claims billed with invalid provider specialty types:   CARC 185:  The rendering provider is not eligible to perform the service billed.  NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    RARC N95:  This provider type/provider specialty may not bill this service.   MSN 21.18:  This item or service is not covered when performed or ordered by this provider.   Spanish version:  Este servicio no esta cubierto cuando es ordenado o rendido por este proveedor.   Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  160.3 - Correct Types of Bill (TOB) for IBT for CVD on Institutional Claims  (Rev. 2432, Issued: 03- 23-12, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04-02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   Effective for claims with dates of service on and after November 8, 2011, the following types of bill (TOB) may be used for IBT for CVD: 13X, 71X, 77X, or 85X.  All other TOB codes shall be denied.