Lost Opportunity in Tobacco Cessation Care: Impact of Underbilling in a Large Health System

Abstract

Importance: Tobacco cessation remains a critical challenge in healthcare despite the availability of evidence-based interventions, which are under-utilized. Tobacco cessation services can be provided and billed at every office visit, but full implementation is impeded by misaligned economic incentives and inadequate training. Objective: To evaluate the potential revenue loss in tobacco cessation care due to inadequate service delivery and billing practices, measuring the impact of systems-based approaches in population health for tobacco cessation. Methods: In this retrospective cohort study, aggregated de-identified patient-level health data was used to estimate smokers eligible for cessation counseling and analyze billing practices from 1/1/21 to 12/31/23. Using claims and electronic medical record data, potential revenue was calculated using the Medicare reimbursement rate and standard multipliers for smoking cessation services. Setting: Data across an 8-hospital regional health system with over 200 outpatient care locations across Pennsylvania and Maryland were examined. Participants: A total of 584,631 unique patients meeting inclusion criteria were identified, with 75,115 smokers eligible for cessation counseling. Intervention(s)/Exposure(s): Primary care encounters eligible for smoking cessation counseling (CPT codes 99406 or 99407) were analyzed over a three-year period. Main Outcome(s) and Measure(s): The billing rate for cessation counseling was calculated at both the patient and visit levels, revealing a discrepancy between eligible encounters and billed services. The estimated potential revenue loss over three years was $5,947,018.13. Results: Over the three years, 584,631 total primary care patients were seen. 75,115 (12.8%) were identified as smokers, who had 507,656 visits, and of these, only 1,277 patients were billed. This reflected a billing rate of 1.7%, with a potential unrealized revenue totaling $5,947,018.13 over three years. Conclusions and Relevance: The study identifies a disparity between potential and actual billing for smoking cessation, indicating missed opportunities for healthcare systems. This highlights a need for enhancing billing practices for smoking cessation, emphasizing the need for improved billing practices and systemic changes to enhance intervention efforts. Policy changes that incentivize proper billing could promote the public health benefits of improving smoking cessation interventions.