Reimbursement for obesity counseling

December 7, 2018

Is there reimbursement specifically for weight management counseling?

Q: Is there reimbursement specifically for weight management counseling?

A:  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. This code reimburses at about $25, and is for patients with a (BMI) of 30 kg/m2 or greater. 

According to CMS, therapy for obesity consists of:

  • Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed 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.

Additionally, the NCD states that the intensive behavioral intervention for obesity should be consistent with the 5-A framework that has been delineated by the USPSTF:

Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing help and support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Medicare will pay for G0447 up to 22 timesin a 12-month period, counted from the date of the first claim. The valid ICD-10 codes will be Z68.30-Z68.39, Z68.41-Z68.45. Check with your local Medicare Administrative Contractor (MAC) for clarification on the ability to bill more than one unit per visit. Medicare coinsurance and Part B deductible are waived for this service, and the service. 

The patient must be competent and alert at the time of counseling, which may be provided by primary care physicians, advanced practice nurses and physician assistants. These services also can be performed by auxiliary personnel when incident-to guidelines are met.

For Medicare beneficiaries with obesity, CMS covers one face-to-face visit every week for the first month and one face-to-face visit every other week for months two through six. A weight loss reassessment needs to be performed at six months, and those patients who have lost at least 3 kg during the six months will then be eligible for once a month visits for an additional six months.

In order to bill this code, the time must be documented in the medical record.  The physician cannot bill for more than a 15-minute interval. If more time is spent with the patient, the total time should be noted in the record. 

This service must be provided by a primary care physician or other primary care practitioner. The place of service is also specific for this therapy to be performed. It must take place in a physician’s office, outpatient hospital clinic, an independent clinic, or a public health clinic.

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Ind. Send your coding questions to medec@ubm.com.

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