Gastroenterology Coding Alert

Hint: You won’t always be able to report 99401 with an E/M.

When patients present to your GI practice with fatty liver, many gastroenterologists follow up the evaluation with obesity counseling and weight loss management services. But coding these visits can create a host of problems if you report them incorrectly.

Check out four tips that can help you select the right codes for obesity management every time.

Tip 1: Don’t Report 99401 With E/M Codes

While all alcohol use, tobacco use, and weight loss counseling have individual CPT^® codes a provider may report, it’s important to understand what situations allow for a provider to report a specific counseling code. Consider the following weight loss counseling CPT^® codes:

• 99401 (Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes)
• 99402 (… approximately 30 minutes)

A subscriber wrote to Gastroenterology Coding Alert asking how to code when a fatty liver patient is evaluated, followed by additional weight loss management and obesity counseling. “We have billed 99212 (Office or other outpatient visit for the evaluation and management of an established patient) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and then 99401, but commercial payers have been denying the 99401 code,” the subscriber writes.

Some coders may assume that they can bill these codes separately from a patient’s E/M visit. While you may report tobacco and alcohol use cessation counseling codes with an E/M visit, the same cannot be said for obesity counseling codes.

Here’s why: CPT^® codes 99401 and 99402 have a “separate procedure” designation, which means that they are included in a more comprehensive service performed during the same encounter/same day. So, you would not bill a problem-focused E/M service and 99401 or 99402 on the same day.

In fact, CPT^® states that “risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.” That means you cannot use these codes (99401-99404) when the counseling is provided as part of the treatment for an illness.

Tip 2: Meet the Criteria for Weight Loss Counseling

The patient must be found to have a body mass index (BMI) of 30 or more to justify reimbursement for weight loss counseling, according to most payers’ policies.

Remember: Determining a patient’s BMI is also useful as a means of reporting Merit-based Incentive Payment System (MIPS) measures. However, in order to document MIPS measure #128 (Preventive care and screening: body mass index (BMI) screening and follow-up plan), make sure you have reached the denominator criteria. While MIPS reporting is exclusive to patients ages 18 and up, physicians can still counsel and bill for patients on weight loss under the age of 18.

For eligible Medicare patients who meet the BMI criteria for weight loss counseling, Medicare will reimburse for:

• One face-to-face visit every week for the first month;
• One face-to-face visit every other week for months two through six; and
• One face-to-face visit every month for months seven through 12, if the member meets the 3-kg (6.6-lb.) weight loss requirement during the first six months.

When providers opt to include weight loss counseling as a part of the E/M visit, they may want to consider using time as the determining factor for E/M code choice, as the time the physician spends counseling the patient may support a higher level of service.

Caveat: Choosing E/M codes based on time is tricky; check with your provider and coding manager before coding an E/M based on encounter time, and always ensure that the documentation notes the total time of the visit, the time counseling/ coordinating care, and a note mentioning what was discussed.

Tip 3: Avoid G0447 in Most Situations

You are not likely to use the HCPCS Level II code G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) for these patients, because this code designated for primary care providers using the intensive behavioral therapy (IBT) technique to counsel patients.

You’ll find nine specialties that can collect for G0447, according to MLN Matters article MM7641. These include internal medicine, ob/gyn, geriatrics and other specialties, but not gastroenterology. “In theory, a nurse practitioner or physician assistant can bill G0447 for Medicare patients but in at least some localities these practitioners are linked to the gastroenterology specialty code of their practice and the contractor may not recognize the ‘approved’ specialty code for NP or PA,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

Tip 4: Sequence Your Diagnoses Properly

You should use the initial baseline BMI as the first diagnosis code and pertinent comorbidities as secondary codes (e.g., fatty liver, type 2 diabetes mellitus, hyperlipidemia), Littenberg says. “Continue to use the baseline BMI in subsequent claims even after the patient has successfully lost weight.”