Medicare Compliance & Reimbursement

Tip: Count both individual and group counseling services provided to the patient.

When your physician uses his expertise to counsel a patient about obesity, the last thing you want to face is a denial for these services. Keep track of, document, and report the number of sessions that receive coverage — and track provider and POS requirements to ensure that you help your patient achieve goals without risking pay.

When your physician performs counseling for obesity, you’ll have to report one of the following HCPCS G codes:

• G0447 (Face-to-face behavioral counseling for obesity, 15 minutes)
• G0473 (Face-to-face behavioral counseling for obesity, group [2-10], 30 minutes)

Background: You can report G0447 if your patient has a body mass index (BMI) of 30 kg/m2 or higher and your physician performs obesity counseling. Medicare will reimburse you for one visit per week for the first month and one visit every other week between months two and six. In addition, if the patient loses 6.6 pounds during the first six months, he is eligible for an additional visit every month for months seven through 12.

Catch G0473 For Obesity Group Counseling

Beginning Jan.1, 2015, you have a new code that the Centers for Medicare & Medicaid Services (CMS) has introduced for obesity counseling provided to a group of 2-10 individuals over a 30-minute period. You will report this with the HCPCS code, G0473. You will report one unit of this code for every individual in the group that participates in the group counseling.

“The key difference is that code G0477 is for obesity counseling with an individual one-one-one, while G0473 is for obesity counseling in a group setting,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “It’s probably also worth noting that G0473 covers groups of up to 10 individuals, suggesting that Medicare does not cover or pay for obesity counseling with groups larger than that.”

Note that CMS will only provide coverage for obesity counseling for a total of 22 sessions for a patient in a 12-month period. You will have to count both individual and group counseling services provided to the patient and the total of these should not be more than 22 sessions in a year’s time.

Example: Your provider performs group counseling for obesity for a group of five individuals. Since your clinician performed this service for five persons, you will have to report G0473 for each of the individuals in the group and not G0473 once for the entire group. So, in this instance, you will report G0473 five times, once for each person.

Documentation: If your physician performs obesity counseling, keep the “Five A” strategy in mind when completing your documentation to ensure that the following five factors are in your documentation:

1. Assess. Ask the patient about his behavioral health risk and any factors impacting his choice of behavior change goals and methods.

2. Advise. Offer clear and specific personalized behavior change advice, with information about personal health harms and benefits.

3. Agree. Work with the patient to choose treatment goals and methods that the patient will likely be willing to perform.

4. Assist. Help the patient achieve his goals via behavior change techniques like counseling so he can get the skills, confidence and support required to follow the plan, supplemented with adjunctive medical treatments when appropriate.

5. Arrange. Schedule follow-ups to continue to support the patient and adjust the treatment plan when necessary.

Provider and POS requirements: Ensure that the chart reflects that a qualified provider performs the screening and counseling. The screening and the counseling should be performed by the beneficiary’s primary care physician (which CMS defines as general practice, family practice, internal medicine, obstetrics/gynecology, pediatric medicine, or geriatric medicine) or by the beneficiary’s physician assistant, nurse practitioner, or certified clinical nurse specialist. “Note that CMS also limits coverage and payment to certain sites of service,” Moore points out.

According to section 200 of chapter 18 of the Medicare Claims Processing Manual, CMS only pays for the service if it is provided in one of the following places of service:

Physician’s Office (Place of Service 11)
Outpatient Hospital (Place of Service 22)
Independent Clinic (Place of Service 49)
State or local public health clinic (Place of Service 71)

Don’t Forget to Include the Appropriate Diagnosis Codes

Irrespective of whether your clinician is performing individual or group obesity counseling, you will have to support the counseling with an appropriate diagnosis code. Since one of the requirements for performing obesity counseling is a BMI that is equal or higher than 30 kg/m2 you will have to report an appropriate code to reflect the BMI of the patient to support the need for counseling. If you are using ICD-9 codes, you will have to use one of the codes for BMI 30.0-BMI 70 (V85.30-V85.39 and V85.41-V85.45).

When you begin using ICD-10 codes after Oct. 1, 2015, you will have to switch over to using one of the codes from the ranges, Z68.30-Z68.39 and Z68.41-Z68.45 depending on the patient’s BMI to support the need for obesity counseling.

For more information on obesity counseling, check the Medicare Claims Processing Manual at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf and the MLN Matters article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8874.pdf.