CPT CODE and Description
• 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.
This policy describes Optum’s requirements for the reimbursement and documentation of “Obesity Screening and Counseling” –CPT codes 99401 and 99402, and HCPCS procedural codes G0446, G0447 and G0473.
The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.
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
COUNSELING, RISK FACTOR REDUCTION, AND BEHAVIOR CHANGE INTERVENTION CODES
▶ Used to report services provided for the purpose of promoting health and preventing illness or injury.
▶ They are distinct from other E/M services that may be reported separately when performed. However, one exception is you cannot report counseling codes (99401–99404) in addition to preventive medicine service codes (99381–99385 and 99391–99395).
▶ Counseling will vary with age and address such issues as family dynamics, diet and exercise, sexual practices, injury prevention, dental health, and diagnostic or laboratory test results available at the time of the encounter.
▶ Codes are time-based, where the appropriate code is selected according to the approximate time spent providing the service. Codes may be reported when the midpoint for that time has passed. For example, once 8 minutes are documented, one may report 99401.
▶ Extent of counseling or risk factor reduction intervention must be documented in the patient chart to qualify the service based on time.
▶ Counseling or interventions are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.
▶ Cannot be reported with patients who have symptoms or established illness
Obesity screening and counseling is one of a number of distinct preventive services mandated by national and state regulations [US Dept. of Labor]. The USPSTF recommends screening all adults for obesity [Moyer]. The screening of children >6 years old is also recommended in a separate report [USPSTF]. The USPSTF did not find sufficient evidence for screening children younger than age 6 years. Many different types of providers – not limited to but including chiropractors, physical and occupational therapists – can offer screening and counseling for obesity [Frerichs, Ndetan]. Screening for obesity is typically performed by calculating body mass index (BMI). Counseling and behavioral interventions generally consist of problem-solving (assisting by providing specific suggested actions and motivational counseling) and facilitating access to social support services (arranging for services and follow-up) [ChiroCode, MLN].
Medicare covers screening for adult beneficiaries with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2
, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Those who meet these criteria are eligible for:
• 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 beneficiary meets the 3kg (6.6 lbs.) weight loss requirement during the first 6 months [MLN].
For beneficiaries 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. Medicare does not allow the billing of other services provided on the same day as an obesity counseling visit, but private plans have a wide array of policies on such care. They vary with regard to how the visit should be coded, how many visits are allowed in a year, and in reimbursement design [Elliott].
For children and adolescents ages 6-18 years, the USPSTF uses the following terms to define categories of increased BMI:
• Overweight = an age/gender-specific BMI between the 85th and 95th percentiles
• Obesity = an age/gender-specific BMI at or above the 95th percentile.
The USPSTF did not find any evidence describing the appropriate timing of screening intervals.
Service Procedure Codes Diagnosis Codes
Screening for obesity in adults, children and adolescents Preventive Medicine Individual Counseling:
• 99401 – 99404 (Diagnosis Code Required) Behavioral Counseling or Therapy:
• G0446, G0447, G0473 (Diagnosis Code Not Required)
• ICD‐10: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45
• ICD‐10: E66.01, E66.09, E66.1, E66.8, E66.9