Obtaining Reimbursement for Preventive Counseling Services

An article in the most recent issue of the Journal of Oncology Practice discusses Medicare and private payer coverage of cancer prevention counseling for persons in certain risk categories. Authors, including Practice Manager Insider’s own Elaine Towle, surveyed medical directors for 6 private payers and 4 Medicare carriers about coverage of cancer prevention counseling. Following are some of the other findings:

• Few formal Medicare coverage policies on cancer prevention counseling exist at either national or local levels. The exception is national coverage for a smoking cessation counseling benefit under two conditions: if the beneficiary has an illness caused or complicated by tobacco use, or if the effectiveness of the beneficiary’s medication(s) is complicated by tobacco use.
• Medicare carrier medical directors interviewed believed that cancer prevention counseling would be covered for a patient with an established cancer diagnosis, a precancerous condition, or a high risk of familial cancer.
• Most private payers do not have formal coverage for preventive counseling but do pay for cancer preventive counseling delivered to a patient with a precancerous condition or a personal or family history of cancer.
• Cancer prevention counseling by a medical oncologist generally will be billed using established evaluation and management (E/M) codes, said both Medicare and private payer medical directors. The exception for Medicare carriers would be that intermediate and intensive smoking cessation counseling should use the new codes provided for those services.
• Neither Medicare nor private payer medical directors require specific documentation in the patient medical record for cancer prevention counseling. Both referred to the CPT guidelines for reporting E/M services, which must justify the level of service billed. Medicare’s policy states that time is the key determinant of E/M level of service when >50% of the face-to-face patient/family-physician encounter is dedicated to counseling.

http://jop.stateaffiliates-asco.org/September06Issue/214.pdf