Intensive Behavioral Therapy for Obesity

Did you know that Medicare now has coverage provisions for behavioral therapy for obesity? Effective with dates of service November 29, 2011 and forward, Medicare beneficiaries with obesity are eligible for a series of face-to-face visits with a primary care physician. For these services, the Medicare Part B deductible and coinsurance are waived.

MedLearn Matters article number MM7641 outlines all the specifics related to this provision, but here are some key points and excerpts from this article for physicians who want to provide and bill for this service.

First of all, an obese patient is defined as one who has a Body Mass Index (BMI) equal to or greater than 30 kg/m2. The patient must be competent and alert at the time of counseling, and the service must be provided by a qualified primary care physician. If the above criteria are met, each patient can receive the following series of visits:

  • One face-to-face visit every week for the first month
  • One face-to-face visit every other week for months two to six
  • One face-to-face visit every month for months seven to 12, if the beneficiary meets the 3 kg (6.6 lbs) weight loss requirement during the first six months

At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss should be performed. To be eligible for additional face-to-face visits occurring once a month for months seven to 12, beneficiaries must have achieved a reduction in weight of at least 3 kg (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 beneficiaries who do not achieve a weight loss of at least 3 kg (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.

The counseling visits should consist of the following:

  1. 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)
  2. Dietary (nutritional) assessment
  3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise

Intensive behavioral intervention for obesity should be consistent with the 5-A framework:

  1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. 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.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

When billing for these visits, the physician will use HCPCS code G0447, and use one of the following ICD-9 codes for BMI 30.0 and over: V85.30 through V85.39, V85.41 through V85.45.  You will experience denials for HCPCS code G0447 if you do not use one of these diagnosis codes.  For 2012, $24.23 is the North Carolina allowed amount for G0447 when provided in the non-facility setting.

Frequency limitations exist for this service.  Medicare will pay for G0447 no more than 22 times in a 12-month period.  In general, obesity counseling is not separately payable with another encounter on the same day except for times when it’s billed with the Initial Preventive Physical Examination (IPPE), Diabetes Self Management Training, and Medical Nutrition Therapy services.

For additional information you can refer to the MedLearn Matters article number MM7641. The official instruction, CR 7641, issued to your FI, Carrier and A/B MAC regarding this change, was issued in two transmittals at the following links:

Many of the Medicare Advantage plans which replace Part B coverage will also recognize these services, but it is recommended you contact those specific payers for guidelines and payment amounts.

CMS has implemented similar provisions for the identification/prevention of conditions such as cardiovascular disease, depression, and alcohol misuse.