Making the Most of Medicare Obesity Reimbursement – thoughts from a coding perspective

I think Medicare picking up the tab for a defined number of visits would be a help to a practice that wants to start-up a new revenue center. I think the PCP who only sees obese patients periodically, and only when they arrive to the office for a Diabetes or HTN check would not necessarily gain the full advantage of the use of this G0447. I would advise my clients to consider creating a section of their practice designed specifically for obese patients.

Here is how I would proceed:
The HTN or Diabetic patient is seen in the office, either in follow up or initial. The patient’s BMI meets the 30 kg/m2 minimum requirement. Spend 15 minutes discussing the Intensive Behavioral Therapy (IBT) program (for which the provider would have established informational materials). I would bill Medicare for the appropriate E/M level of service that has been documented, and append a modifier -25. The dx code used for the office visit should agree with the chief complaint and/or findings (e.g. HTN, Diabetes). I would then bill HCPC code G0447 and use the diagnosis codes referred to in the Medicare bulletin dated 3/2012. The bulletin suggests Medicare may reimburse both codes when appropriate.

Note: The bulletin suggests a modifier 59 is payable, but that modifier is for procedures and not E/M codes. Note that each Medicare MAC may invent its own set of reimbursement rules, where one MAC pays, and other one does not.

I have seen a new tab, in the Medicare eligibility screen for patients, which indicates the number of visits used and available. So, Medicare will stop paying when the patient has met the number of visits allowed per year.

I do see a problem with starting an IBT program; the patient may be seen by any number of qualified providers, and each may submit the G0447 code for payment.

An example would be the female patient who is seen by her primary provider for HTN and is counseled in IBT and that provider submits a claim for G0447. Then, she sees her OB/GYN for her annual exam, and the GYN counsels her and submits G0447, then she sees her Internal Medicine doc in follow up for Thyroid, and is counseled in IBT and that providers submits a claim for G0447, thereby eliminating 3 of the 24 allowed visits per year. If the patient is in an IBT program with a practice, the patient should be told to let her other providers know this, in the hope that overuse of G0447 will not occur.

I see this code as useful for those practices that have a business plan to offer IBT as a part of an Obesity “clinic” or program. The description and use of the G0447 that I have, demonstrates that Medicare is looking for such a program as well. The patient has to meet certain milestones in order for the physician to continue using code G0447.

Having said all of that, if the practice agrees to establish a certain focus for obese patients (this would be great for those practices who know who their obese patients are….they should be able to run a report from their billing system to determine the number of patients with an obesity dx code), the next step would be to have a provider available to manage the IBT program. From what I have read, a NP or PA or Certified Clinical Nurse Specialist may provide the services.

The patients should be scheduled only for the IBT visit. If the patient needs to be seen for other clinical issues, they should be scheduled for another day. Of course, all of this is only for Medicare….non-government payors will have their own set of Preventive Care rules….

Maureen

7 thoughts on “Making the Most of Medicare Obesity Reimbursement – thoughts from a coding perspective

  1. Maureen,

    I’m confused. I’ve had two separate billing managers tell me the following:

    “For a G0477, Medicare will pay $25.09 (for a 15 min session). Medicare states: “Obesity counseling is not separately payable with another encounter/visit on the same day.”

    You state in your post, “The bulletin suggests Medicare may reimburse both codes when appropriate.”

    The key words here are, “may reimburse both codes.” Can any physician afford to take the chance of being turned down when the GO477 reimbursement is only $25.09? Can he/she afford an audit after six months when he/she has billed 500 GO477s as part of a new revenue service? I don’t know any physicians who will take this chance. (and 500 IBT GO477s is only $12,500)

    The average annual salary of an NP or PA in many states is over $100,000 or over $50 per hour. Throw in 30% for overhead and then the cost of billing and it is hard to see how any primary care physician could do anything but loose money on providing obesity counseling for Medicare patients and that’s through a lower cost mid level provider. Even if they could do group appointments, the reimbursement simply isn’t enough to even begin to cover costs.

    There is no question weight management could help many people and might even reduce health care costs in the long run. However, it’s hard to see how that could possibly happen with this CMS program.

    If it was possible to do a group appointment for 2 hours for 15+ patients that could be billed individually at a level 2 or level 3 E/M plus a GO477, this program would be viable and well worth the effort.

    But in the absence of this approach, most of the physicians I have talked to believe this program is DOA. Please tell me how they are wrong.

  2. I hope I’m wrong but I think your advise on billing for an E/M with a modifier 25 is not only wrong but dangerous for any provider who follows it without getting written authorization from their MAC provider.

    This is the link to the March CMS guidelines for billing for obesity counseling:

    http://www.cms.gov/transmittals/downloads/R2421CP.pdf

    The guidelines allow for:

    One face-to-face visit every week for the first month;
    One face-to-face visit every other week for months 2-6;
    One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement during the first 6 months.

    CMS instructions to MAC providers are that they shall deny claims using code – 7641-04.8.1 which states:

    “Contractors shall pay for obesity counseling G0447 in RHC TOB 71X and FQHCs TOB 77X based on the all-inclusive payment rate.
    NOTE: Obesity counseling is not separately payable with another encounter/visit on the same day”

    The danger for any physician following your advise is that the E/M billing would be disallowed and only the GO447 would be reimbursed unless you think MACs are going to authorize up to 22 E/M visits for HTN or diabetes in a 12 month time frame and ignore the note that obesity counseling is not separately payable with another encounter on the same day. (and reimbursement for GO447 is only $25.09 so a physician could conceivably deliver a level 4 visit with a GO447 and receive only $25.09 for both if the level 4 visit is disallowed as too frequent)

    Here are links to CMS discussions on the use of modifiers 25 and 59.

    https://questions.cms.hhs.gov/app/answers/detail/a_id/7387/~/when-should-cpt-modifier–25-be-used%3F

    https://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf

    Hope I’m wrong here but if I’m not, your post should be corrected.

  3. You are correct to note that the billing for the code G0447 is complicated at best and consideration should be made when using this code to review the local Medicare billing guidelines. Considerations such as using an ABN, frequency and diagnosis should be reviewed by each practice. You are correct that submitting a claim for an office visit on the same day as an obesity counceling visit may result in non-payment. Medical necessity is the overarching criteria for office visits, and if the purpose of the visit is solely to be counceled for obesity, then the medical necessity criteria may not be met.

    My experience has been that medical practices who already have obesity counseling in place, are using code G0447 successfully. What is evident is Medicare has acknowledged the need for its’ beneficiaries to have an option to participate in an obesity program. Hopefully, other payors will follow and offer obesity counceling as a benefit to their participants!

  4. Maureen,

    Thanks for the response. When you say it is your experience that medical practices that already have obesity counseling in place are using G0477 successfully, does that mean they are selling unreimbursed ancillary services and they are just adding G0477 on top of it?

    It would be nice to hear from physicians who are using GO477 and willing to share their experience.

    It’s hard to see how a $25 obesity counseling reimbursement that is lower than a Medicaid office visit is going to accomplish anything of substance.

    I don’t know any physician who can afford to deliver this program as CMS has designed it.

    What is the purpose of designing a program for the general populace that only a tiny fraction of health care providers can afford to deliver?

  5. It appears that the reimbursement is not worth the overhead that a practice will incur to provide this service. I am a bit confused anyway.. I have read the decision memo several times and I do not understand how will the other professionals such as the nutritionist and the professional providing the excercise will benefit from this financially. It states that the care will be coordinated through the PCP who will write an order for the paient to see a nutritionist to address the eating habits and a physical fitness person or someone of that nature to incorporate exercise. My question is even if these professionals are providing this service in the primary care setting how will they be paid? Perhaps, I am not clearly understanding this program. If there is someone who currently have this program in place please explain this component of the program to me.

  6. I would love to hear success stories of any physician practice that is offering an obesity program and utilizing the G0447 code. I am a physical therapist interested in starting an obesity clinic collaborating with a physician, registered dietitian and behavioral health. I would like to make it financially worthwhile for an MD to get involved. $25/15 minutes doesn’t seem even feasible. Any thoughts?

    1. Elisabeth,

      The elephant in the room (pun intended) is that CMS obesity counseling reimbursement levels are so low there is no way for any PCP to deliver this service and make money. A $25 reimbursement for obesity counseling makes Medicaid reimbursement levels look good by comparison.

      The real problems with this program are the CMS restrictions on billing. CMS guidelines for Obesity counseling state they can not be combined with an E/M visit on the same day and group appointments are not allowed.

      I do not know of a single PCP, of the dozens I have talked to, who can afford to do this program for their Medicare patients.

      Perhaps this program could work with a rural clinic run by a PA or NP with a high percentage of Medicare patients that is under volume capacity where a $25 reimbursement would be better than not seeing anyone.

      I would also love hear from any PCP who has found a way to make this program work because the goal is truly worthy. However, the devil is in the details and it is amazing how little focus there has been in the reporting on this subject with analysis of the programs practical implementation.

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