Recent reports show that there is no decline in obesity rates in the US. According to a recently released CDC study, the overall rate of obese adults rose from 33.7 percent in 2007 to 39.6 percent in 2016. This is despite the public health campaign to rein in the obesity crisis and related rise in comorbidities. In the past, primary care providers lacked reimbursement for obesity management. Today, obesity screening and counseling is among the specific preventive services mandated by national and state regulations (US Department of Labor). Medical coding outsourcing can help physicians who provide these services take advantage of the latest payment methodologies designed to improve reimbursement of obesity treatments.
Importance of Obesity Management
Obesity is associated with a wide range of medical problems such as increased risk for coronary heart disease, type 2 diabetes mellitus, various types of cancer, gallstones, and disability. HealthDay recently reported that the percentage of U.S. health spending on treatment of obesity-related illnesses in adults increased from just over 6 percent in 2001 to almost 8 percent in 2015 – an increase of 29 percent.
With the associated burden of chronic diseases, obesity is also linked with higher risks of mortality, especially in people younger than 65 years. Weight loss could lower risk of health concerns and death.
Definitions of Overweight and Obesity
Body Mass Index (BMI) is calculated by dividing a person’s weight in kilograms by the square of the person’s height in meters, that is, BMI = weight/height2.
In June 2017, the US Preventive Services Task Force (USPSTF) recommended clinicians screen for obesity in children and adolescents aged 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.
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 also recommends screening all adults for obesity. For adults aged 18 years or older, the USPSTF uses the following terms to define categories of increased BMI:
- Overweight = a BMI of 25 to 29.9 kg/m2
- Obesity = BMI of 30 kg/m2or higher
The USPSTF that clinicians should refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. Such programs typically include group sessions (at least 12 sessions or more in the first year) and help patients make healthy eating choices, encourage them to increase physical activity and help them monitor their own weight.
Diagnostic Codes for Obesity Screening
The ICD-10 diagnosis code that may be reported for obesity screening is:
- Z13.89 Encounter for screening for other disorder
To report a diagnosis of obesity, the relevant ICD-10 codes come under the code section E66 and are organized, as AAPC explains, based on severity, contributing factors, and manifestation. Reported codes include:
- E66.9 Obesity not otherwise specified
- E66.01 Obesity, extreme or morbid
- E66.0 Obesity due to excess calories
- E66.01 Morbid (severe) obesity due to excess calories
- E66.09 Other obesity due to excess calories
- E66.1 Drug-induced obesity(An instructional note states that an additional code should be used for adverse effect, if applicable, to identify the drug)
- E66.2 Morbid (severe) obesity with alveolar hypoventilation
- E66.3 Overweight
- E66.8 Other obesity
- E66.9 Obesity, unspecified
A BMI code should be reported along with the obesity diagnosis code if BMI is known.
Body Mass Index Codes
Category Z68 contains the ICD-10 codes to report BMI values.
BMI adult codes are for use for persons 21 years of age or older and are based on the numerical scale (e.g., 28.0–28.9). Pediatric BMI codes are for use for persons 2-20 years of age and are based on the percentile for age range (e.g., 5th percentile to less than 85th percentile).
The fourth and fifth characters of ICD-10 BMI codes match the BMI number until BMI reaches a value of 40.0. For e.g., the American College of Obstetricians and Gynecologists (ACOG) states that a BMI of 30 would be reported with code Z68.30 BMI 30.0–30.9, adult. As BMI is known, the ICD-10 codes reported for an obese patient with a BMI of 30 and no other indications would be E66.9 and Z68.30.
For BMIs that are greater than 40, body mass index is reported as follows:
- Morbid obesity with BMI 40.0–44.9 adult Z68.41
- Morbid obesity with BMI 45.0–49.9 adult Z68.42
- Morbid obesity with BMI 50.0–59.9 adult Z68.43
- Morbid obesity with BMI 60.0–69.9 adult Z68.44
- Morbid obesity with BMI 70.0 and greater Z68.45
Screening for Obesity – Procedural Codes
- Medical Nutrition Therapy : CPT codes 97802 – 97804
- 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
- 97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
- 97804 Medical nutrition therapy; group (2 or more individual(s), each 30 minutes
- Preventive Medicine Individual Counseling : CPT codes 99401 – 99404
Codes 99401–99404 are used to report counseling services in areas such as family problems, diet, and exercise. These time-based codes may be reported separately from other E/M services (such as office visits or preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401–99404 to indicate to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.
- Behavioral Counseling or Therapy :
The following HCPCS codes may be reported for Medicare beneficiaries who receive intensive behavioral therapy for obesity –
- G0447 – Face-to-face behavioral counseling for obesity, 15 minutes
- G0473 – Face-to-face behavioral counseling for obesity, group (2–10), 30 minutes
- G0447 – Face-to-face behavioral counseling for obesity, 15 minutes
In its April 2017 reimbursement guideline, private carrier Optum clarifies that Medicare covers screening for adult beneficiaries with obesity (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.
For eligible adult health plan members with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2, Optum aligns 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
- 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]
A reassessment of their readiness to change and BMI is appropriate after an additional 6-month period 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. These visits must be provided by a qualified health care provider.
Points to Note
- When evaluating a patient for obesity, clinicians should also assess comorbidity conditions that is being treated or that affect the treatment, and report the additional diagnoses codes for those conditions you evaluated that affected this specific visit, linked to the appropriate evaluation and management (CPT) code.
- Medicare does not allow the billing of other services provided on the same day as an obesity counseling visit. However, commercial plans have a wide array of policies on such care, which differ as regards how the visit should be coded, how many visits are allowed in a year, and in reimbursement policy.
- Coding should be done to the highest degree of specificity. ICD-10 codes should be linked to the CPT codes on the claim.
- The codes assigned should represent an accurate description of “what” was performed and “why” it was performed and be supported by medical documentation, including time spent with the patient.
- Besides documenting that the coverage conditions were met, the medical record must include verification of the counseling intervention (Medicare recommends documenting the 5-A approach highlighted by the USPSTF).
To report obesity screening and treatment correctly, clinicians need to be up-to-date with ICD-10 and CPT codes as well as Medicare and private payer guidelines. With extensive coding and documentation challenges, the support of an experienced medical coding service provider can go a long way in ensuring accurate submission of claims and proper reimbursement.