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How to bill for screening and treating obesity in adults

A column about keeping your practice in good health

By Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009. Posted Sept. 3, 2012.

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More than a third of adults are obese, but even when patients are willing and able to enter treatment, primary care physicians have not always gotten paid for the screening and treatment.

That is no longer true. Money usually is not available for obesity screening as a separate service, but practices may earn bonuses for doing so within various quality pay structures. In many cases, treatment is a billable service.

“You can do it,” said Thomas McKnight, MD, MPH, a family physician in Hurlburt Field, Fla., who runs ObesityRX, a consultancy to help primary care physicians incorporate obesity treatment into their practices. “You just have to think differently.”

The first step is to implement a screening protocol to identify patients who are most likely to benefit from obesity treatment and counseling. This probably will be done by a medical assistant or someone else at the practice who takes vitals, including height and weight, and then calculates body mass index. Some electronic health records have built-in BMI calculators. Several are available online at no charge. Adults with a BMI greater than 30 are classified as obese.

Calculating a BMI for patients and documenting a follow-up plan if the weight is high is one measure practices can use to qualify for meaningful use incentive payments from the Centers for Medicare & Medicaid Services for implementing an EHR. Other bonuses may be earned within an accountable care organization or patient-centered medical home.

“It’s worth looking at these bonuses,” said Trent Shelton, an owner of Solutions4MDs, a medical billing and consulting firm based in Durham, N.C.

Tactful conversation

The next step is to figure out a way to bring up the issue to avoid driving patients away if they don’t want to tackle weight at that time. Some practices have numerous posters and fliers on the issue in hopes that patients will bring up the subject. If a physician raises the topic, people who treat obesity suggest emphasizing the benefits of weight loss rather the horrific things that may happen if patients stay heavy. If the patient declines, the practice may want to devise a system that reminds a physician to bring up the subject when the patient returns.

“Watch your tone of voice and body language,” Dr. McKnight said. “Say how much you care about your patients. If a patient doesn’t want to deal with it, that’s their choice, but you can make it clear how important it is.”

If patients want help with weight loss, follow-up visits are billable. The Affordable Care Act requires most health insurance plans, including Medicare, to cover many preventive services fully without cost-sharing with patients, including intensive counseling and behavioral interventions to promote sustained weight loss.

Many of those with private health insurance plans have had full preventive services coverage since early 2011. Medicare started paying for this service on Nov. 29, 2011.

For Medicare patients, practices should use the HCPCS code G0447 for a 15-minute visit accompanied by the appropriate ICD-9 code ranging from V85.30 to V85.45, depending on the BMI. For example, V85.30 is for those with a BMI of 30 to 30.9, V85.31 is for BMI 31.0-31.9 and V85.45 is for those with a BMI of 70 or more. Shorter visits are not billable. The patient must be competent and alert at the time of counseling, which may be provided by primary care physicians, advanced practice nurses and physician assistants.

Medicare will pay about $25 for one face-to-face visit every week for the first month of obesity treatment for adults with a BMI greater than 30. The charge remains the same, but visit frequency goes down to every other week for the second through sixth month of treatment. If the patient loses at least 6.6 pounds in the first six months, they may receive one face-to-face visit per month for the next half-year.

Medicare recommends using the “five A’s” for treatment: ask, assess, advise, assist and arrange. This strategy is commonly used for smoking cessation and includes an assessment of health risks, advice about behavior change and agreement about strategies and goals. Patients should also be assisted with behavior change and arranging ongoing assistance and support.

Medical practice consultants say this level of payment may allow some primary care practices to create service lines dedicated to this area for Medicare patients. These appointments may take up the slack during slow times.

Medicare is not allowing 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 how much will be paid. The most likely CPT codes are 99401, which covers a 15-minute risk-reduction counseling session, and 99402, which denotes 30 minutes. Other preventive health issues may come up during this period. The ICD-9 code for patients with commercial insurance is V70.0.

“It makes sense to call some of your bigger payers to find out what kind of structure they have in place,” Shelton said.

If a medical problem emerges requiring a co-pay for treatment, that is more complicated. Depending on the situation, some practices ask patients to make another appointment. Other practices address problems that come up then and there, charging a co-pay or deductible as appropriate. This integrates obesity counseling with other care and may make it more likely that the patient will value what is received.

“We’re almost always dealing with blood pressure and diabetes as well as weight,” said John Frederick, MD, a family physician and managing partner at Premier Family Physicians in Austin, Texas, who regularly works with patients on weight issues and bills for these services. “And we tend to get better compliance when patients have to pay something.”

Pay is not always available for the treatment and counseling of patients who are overweight but not obese. Adults are defined as overweight if they have a BMI of 25 to 30.

Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009.

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