Coding Guidelines
for Screening and counseling services
Medicare:
Medicare does
not allow the billing of other services performed on the same day as an obesity
counseling visit.
Screening Services Codes:
G0101, G0102,
Q0091, G0442, G0444
Reimbursement Guidelines:
The
comprehensive nature of a preventive medicine code reflects an age and gender
appropriate examination. When a "Screening
code is billed with a preventive medicine code" on the same
date of service by the Same Specialty Physician or Other Health Care Professional,
"only the preventive medicine code is
reimbursed".
Obesity counseling is
not separately payable with another encounter/visit on the same day. For services that contain HCPCS
code G0447 with another encounter/visit with the same date of service, the
service line with HCPCS G0447 will be denied.
This intensive behavioral
therapy service is considered to be included in the payment/allowance of other
encounter services provided on the same date of service.
This does not apply for Initial
Preventative Physical Examination (IPPE) claims, claims containing modifier 25 indicating
a significant and separate E/M service as distinct from the obesity counseling
For eligible
adult health plan members with obesity, defined as Body Mass Index (BMI) equal
to or greater than 30 kg/m2, optum will align reimbursement with Medicare
including:
- One face-to-face visit every week for the first month;
- One face-to-face visit every other week for months 2-6; and
- One face-to-face visit every month for months 7-12 [if the member meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months.]
For adult
members who do not achieve a weight loss of at least 3 kg (6.6 pounds) during
the first 6 months of intensive therapy, a reassessment of their readiness to
change and BMI is appropriate after an additional 6-month period.
These visits
must be provided by a qualified health care provider.
For eligible
children and adolescent (6-18 years) health plan members with overweight,
defined as having an age/gender-specific BMI at or above the 85th percentile,
Optum will align reimbursement with the recommendations of the U.S. Preventive
Services Task Force.
CPT codes for obesity screening and
counseling are:
- 99401 Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 15 minutes
- 99402 Preventive medicine counseling and/or risk factor intervention/s provided to an individual (separate procedure); approximately 30 minutes
HCPCS codes related to obesity
screening and counseling are:
- G0446 Annual, face-to-face intensive behavioral counseling (IBT) for cardio-vascular disease (CVD), individual, 15 minutes
- G0447 Face-to-face behavioral counseling for obesity, 15 minutes
- G0473 Face-to-face behavioral counseling for obesity, group (2–10), 30 minutes.
Counseling Services Codes:
0403T, 99401,
99402, 99403, 99404, 99406, 99407, 99408, 99409, 99411, 99412, G0296, G0396,
G0397, G0443, G0445, G0446, G0447, G0473, H0005, S0257, S0265, S9470, T1006,
T1027
Reimbursement Guidelines:
Preventive Medicine
Services include counseling.
When counseling service codes are billed with a preventive medicine code on the
same date of service by the Same Specialty Physician or Other Health Care
Professional, only the preventive medicine code is reimbursed.
Reference:
1. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/COMM-Preventive-Medicine-and-Screening-Policy.pdf
2. https://www.ethicon.com/na/system/files/2018-03/087494-180207_2018_Obesity_Rmbrsmnt_Fact_Sheet_r8%20%281%29.pdf
3. https://www.myoptumhealthphysicalhealth.com/Documents/Reimbursement%20Policies/0064_ObesityScreeningandCounselingReimbursementPolicy.pdf
