Medical Billing for Obesity Screening and Counseling

Basics of Obesity Screening and Counseling

Obesity screening and counseling are one of a number of distinct preventive services mandated by national and state regulations (US Dept. of Labor). The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for obesity this screening also includes children of >6 years old. CMS began reimbursing physicians for obesity counseling in November 2011, when they introduced Healthcare Common Procedure Coding System (HCPCS) code G0447 (face-to-face behavioral counseling for obesity, 15 minutes). Intensive behavioral therapy for obesity consists of the following: 

  • Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2); 
  • Dietary (nutritional) assessment; and 
  • Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high-intensity interventions on diet and exercise.

Many different types of providers, including chiropractors, physical and occupational therapists can offer screening and counseling for obesity. To be reimbursed, the intensive behavioral intervention counseling must be provided by one of the provider specialties types as General Practice; Family Practice; Internal Medicine; Obstetrics/Gynecology; Pediatric Medicine; Geriatric Medicine; Nurse Practitioner; Certified Clinical Nurse Specialist; and Physician Assistant. For the purpose of this national Medicare coverage determination, the acceptable setting of care and primary care physician has been defined. The recommendations are for the intensive behavioral therapy to be administered in one of these acceptable places of service: Physician’s Office; Outpatient Hospital; Independent Clinic; and State or local public health clinic. 

Coverage for Medicare

For Medicare beneficiaries with obesity, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting, CMS covers: 

  • One face-to-face visit every week for the first month; 
  • One face-to-face visit every other week for months 2-6; 
  • One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement. 

At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg (6.6 lbs) over the course of the first six months of intensive therapy. This determination must be documented in the physician office records for applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight loss of at least 3kg (6.6 lbs) during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six-month period. Medicare coinsurance and Part B deductible are waived for this service.

Preventative Counseling (CPT 99401-9941)

The standard obesity medicine behavioral counseling codes are 99401-99412. These codes are used to report services for the purpose of promoting health and preventing illness. Typically, the 5-A’s approach i.e., ask, advise, assess, assist, and arrange is used. More specific counseling techniques such as motivational interviewing and cognitive behavior therapy may also be employed. These codes are time-based with increments of 15 minutes and cover both individual and group counseling. The wording pertaining to the time requirement states they require approximately 15 minutes. In time-based codes that do not specify ‘at least’ a specific time, the 50 percent rule applies. So, counseling for at least 7.5 minutes codes to a 99401 (approximately 15 minutes), and 22.5 minutes codes to a 99402 (approximately 30 minutes). 

Reimbursement for 99401 is typically on the order of $30-40. While not a princely sum, this is typically a service done in addition to pharmacotherapy management. Apply a 25 modifier, denoting a separate service on the same visit, and this will earn an extra $35 on your standard 99214 reimbursements. Better yet, this coding subset is covered as a preventative service, so insurance pays the entire amount—no patient cost-sharing is allowed. Medicare has its own separate code, G0447, which pays about 25 percent less and comes with more specific coding rules.

Health Behavior Assessment and Intervention Codes (CPT 96156, 96158)

These codes are similar to preventative service counseling, but they deal more with specific behavioral problems often encountered in an obesity medicine practice. These services ‘…are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems,’ according to the American Psychological Association. Consider these codes for specific behavioral problems, such as addiction, eating disorders, and environmental conditions that cause eating problems. 

96156 is an untimed code used for an assessment or reassessment of a behavioral condition, and it reimburses about three times more than a 99401 code. CPT code 96158 is for behavioral intervention. While the code is for the initial 30 minutes of counseling, the 50 percent rule also applies. Be sure to document at least 16 minutes of therapeutic counseling. The code reimburses about twice as much as a 99401 code. There are also group codes, extended time codes, and codes for counseling the family without the patient present.

Please note that the above-mentioned information on medical billing for obesity screening and counseling is provided as a reference only. Applicable reimbursement rates and billing guidelines may change as per the insurance carrier. If you need detailed assistance in medical billing for obesity screening and counseling, then contact us at 888-357-3226 for our billing services.

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