Obesity is a prevalent and complex health issue, demanding a multifaceted approach to treatment and management. Accurate coding and billing practices are essential for healthcare providers to ensure proper documentation, reimbursement, and effective patient care in the realm of weight loss counseling. This article delves into the specific Current Procedural Terminology (CPT) codes relevant to weight loss counseling, providing a detailed overview for medical professionals.
The Significance of Accurate Coding in Obesity Management
Obesity, characterized by excessive body fat accumulation, significantly impacts an individual's health. Precise coding is vital for tracking the condition, supporting clinical decisions, ensuring appropriate reimbursement, and promoting effective patient care management.
Foundational CPT Codes for Obesity Management
Evaluation and Management (E/M) Codes
In the context of weight management, E/M codes are essential for billing both new and established patient visits.
- New Patient Visits: These codes are used for initial evaluations and management of obesity, categorized by the level of medical decision-making and time spent with the patient.
- Established Patient Visits: These codes are used for ongoing management of obesity, documenting the complexity of care and time spent during each visit.
Currently, the maximum reimbursement for weight management is derived from using conventional E&M codes for weight-related comorbidities rather than obesity itself. It is recommended to use one or more weight-related comorbidity as the primary diagnosis and obesity as a secondary diagnosis. Weight-related comorbidities range from metabolic issues to malignancies, mobility issues, and mental health concerns. If a patient has no weight-related comorbidity, an obesity E&M or Z code can be used, although the reimbursement will be lower.
Preventive Counseling Codes: 99401-99412
The standard obesity medicine behavioral counseling codes are 99401-99412. These codes are used to report services for promoting health and preventing illness. The 5-A’s approach-ask, advise, assess, assist, and arrange-is typically employed, along with more specific counseling techniques like motivational interviewing and cognitive behavior therapy. These codes are time-based, with increments of 15 minutes, and cover both individual and group counseling. The time requirement is "approximately 15 minutes," and the 50 percent rule applies. Counseling for at least 7.5 minutes codes to 99401 (approximately 15 minutes), and 22.5 minutes codes to 99402 (approximately 30 minutes). Reimbursement for 99401 is typically around $30-40. This service is often done in addition to pharmacotherapy management. Applying a 25 modifier, denoting a separate service on the same visit, can add an extra $35 to the standard 99214 reimbursement. This coding subset is covered as a preventative service, meaning insurance pays the entire amount with no patient cost-sharing.
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Medicare Code: G0447
Medicare has its own code, G0447, which pays about 25 percent less and has more specific coding rules. CMS began reimbursing physicians for obesity counseling in November 2011 using the Healthcare Common Procedure Coding System (HCPCS) code G0447, which stands for face-to-face behavioral counseling for obesity, 15 minutes.
Medicare pays for ongoing face-to-face behavioral counseling for patients with a body mass index (BMI) of ≥ 30, who are alert and able to participate in counseling. This service may be performed by a physician, a non-physician practitioner (NPP), or medical practice staff incident to the services of a physician or an NPP, assuming all incident to requirements are met and the setting is non-facility.
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 first six months of intensive therapy. This must be documented in the physician's office records. 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 both their readiness to change and their BMI level is appropriate after an additional six-month period.
Health Behavior Assessment and Intervention Codes: 96156, 96158
These codes are similar to preventative service counseling but address specific behavioral problems often seen in obesity medicine practices. These services are used to identify and address psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems. Consider these codes for specific behavioral problems like addiction, eating disorders, and environmental conditions causing eating problems. 96156 is an untimed code used for an assessment or reassessment of a behavioral condition, reimbursing 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 applies, requiring documentation of at least 16 minutes of therapeutic counseling. This 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.
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Coding for Bariatric Surgery
CPT codes for bariatric surgery provide a structured way to document and bill for various weight loss procedures, encompassing both laparoscopic and open techniques used to treat morbid obesity and aid in weight management. For patients undergoing bariatric surgery, additional billing considerations apply.
Additional Considerations for Accurate Billing
The Role of Nurses (RN or BSN)
For an established patient with a care plan for weight-related comorbidities, 99211 is often billable for RN services performed in-person and may be performed via audio-video telemedicine visits if covered by the patient’s plan. There needs to be a clear link between the physician/APP’s initiated and ongoing plan of care and the weight check.
CPT code 99211 may be used to bill for a weight check when the following documentation is present in the nurse's note:
- All vital signs should be recorded
- The clinical reason for the check is clearly documented in the note.
- A list of the patient’s current medications with his/her compliance level.
- The physician's evaluation of the clinical information from the encounter and his or her management decisions.
- Clear identity of the nurse(s) and his or her credentials.
A patient who “drops in” to get a weight check because they are in the area would not qualify for the 99211 because the physician did not order the service and there are no clinical indications to warrant the 99211. A phone-only interaction by the RN would not support a billable service.
Behavioral Health Provider (BHP) Billing
To make engagement in behavioral weight management support for your clinic sustainable, ensure that billing practices support the work. Billing for BHPs in integrated primary care settings depends on factors including state guidelines, credentials, and type of visit. Psychotherapy codes (90791; 90832; 90834; 90837, etc.) require a mental health diagnosis. Patients with a comorbid mental health diagnosis impacting their ability to successfully manage their weight might allow this type of billing. Absent a mental health diagnosis, Psychological Factors Affecting a Medical Condition (PFAMC; F54) may be pertinent in situations in which patients’ behaviors are affecting their obesity. Some private plans permit credentialed licensed clinical behavioral health providers to bill for weight management or nutrition services provided by a non-physician (S9452, S9470, S9449, S9452). The BHP can bill the following Health Behavior CPT Codes: 96156 (health behavior assessment or re-assessment), 96158 (health behavioral intervention, individual, F2F, initial 30 minutes) and 96165 (for each additional 15 minutes). However, providers using this model reported that the visit usually takes longer than 15 minutes.
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Registered Dietitian (RD, RDN) Billing
RDNs can bill directly for medical nutrition therapy (MNT), usually for a total of 3 hours in the first year and 2 hours in subsequent years. Medicare only pays for MNT if there is another condition, such as diabetes and chronic kidney disease. On average, Medicare pays $38 for the initial 15-minute visit (97802), $33 for each subsequent 15-minute visit, or $17 per beneficiary for 30-minute group sessions.
"Incident-To" Billing and Preventative Medicine Codes
Some private payers may permit "incident-to" billing for preventative medicine codes (99401-99404, 99411-99412). Some private plans may require a patient co-pay or co-insurance payment in these situations. Patients can self-pay.
Mandated Preventive Services
Obesity screening and counseling are among the 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 and children >6 years old for obesity. Many providers, including chiropractors, physical therapists, and occupational therapists, can offer screening and counseling for obesity. To be reimbursed, the intensive behavioral intervention counseling must be provided by specific provider types, such as General Practice, Family Practice, Internal Medicine, Obstetrics/Gynecology, Pediatric Medicine, Geriatric Medicine, Nurse Practitioner, Certified Clinical Nurse Specialist, and Physician Assistant. The acceptable setting of care and primary care physician has been defined for Medicare coverage.
Billing 99214 and 99401 Together
Billing both a 99214 and a 99401 on the same day can be complex and is subject to specific guidelines and restrictions. 99401 is used for preventive medicine counseling and/or risk factor reduction intervention provided for 15 minutes. The provider must show that the counseling and risk factor reduction were not part of the evaluation and management service but were instead separate, additional services.
Obesity in Pregnancy
Many patients inquire about weight during their visits with obstetric-gynecologic health care professionals. This resource focuses on coding for Evaluation and Management (E/M) services and obesity during pregnancy.
ICD-10-CM Codes for Obesity
- Obesity is defined by an excess accumulation of body fat that can significantly affect a person’s health. The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) provides specific codes to classify different levels of obesity based on BMI.
- For medical coding, it is crucial to document the patient’s BMI to determine the correct obesity code.
- Obesity should be coded when it is either the primary diagnosis or when it is a contributing factor to other conditions. Common comorbidities associated with obesity include hypertension, type 2 diabetes, sleep apnea, and cardiovascular diseases.
Coverage and Reimbursement
Obesity is now recognized as a medical condition by most major health insurers. However, it is essential to verify coverage for obesity-related services before providing treatment. Medications like orlistat (Xenical), phentermine, and liraglutide (Saxenda) are FDA-approved treatments for obesity. Bariatric surgery is generally covered for patients with a BMI of 40 or higher, or a BMI of 35 or higher with comorbidities, such as type 2 diabetes, sleep apnea, or cardiovascular disease.