Wiki Obesity Counseling and G0447: Who can do it?

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Obesity Counseling and G0447

A dietician may report G0447 to Medicare, under carefully defined requirements.
The current, definitive Medicare guide for reporting obesity counseling as defined by G0447 is MLN Matters® Number: MM7641 Revised <http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7641.pdf>. The article includes counseling requirements, patient eligibility, frequency limitations, and place of service restrictions (i.e., counseling must be furnished in a primary care setting), as well as a list of provider specialty types approved to report the service, to include:
01 - General Practice
08 - Family Practice
11 - Internal Medicine
16 - Obstetrics/Gynecology
37 - Pediatric Medicine
38 - Geriatric Medicine
50 - Nurse Practitioner
89 - Certified Clinical Nurse Specialist
97 - Physician Assistant
Per CMS, “If your specialty type is not one of the above, your claim will be denied…” But, the article goes on to qualify:
Note: In addition, Medicare may cover behavioral counseling for obesity services when billed by the one of the provider specialty types listed above and furnished by auxiliary personnel under the conditions specified under our regulation at 42 CFR Section 410.26(b) (conditions for services and supplies incident to a physician’s professional service) or 42 CFR Section 410.27 (conditions for outpatient hospital services and supplies incident to a physician service).
As such, a dietician may perform obesity counseling as defined by G0447, and the practice may be paid, if the service is properly documented/billed as “incident to” an approved provider’s services (see list, above), in a primary care setting.
Per CMS requirements:
To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service [emphasis in original].
For complete information on Medicare incident to billing rules, see MLN Matters Number: SE0441 (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf).
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The new Obesity Counseling codes (long overdue) say that counseling has to be face to face with a physician or "other qualified Healthcare Practitioner" who I assume is an NP, PA, CNS, etc. I have heard from several dietitians that they intend to do this counseling in the outpatient setting and either bill it with their own NPI number (which is supposed to be used only for MNT counseling as I understand it) OR they intend to have the physician bill for their services as "incident to" billing despite the fact that the dietitians do not work for the practice. Some have suggested that all they need is a collaborative practice agreement with the physician (and other practitioners such as pharmacists use these to bill "incident to" for their services vis-a-vis comprehensive medication review), yet I have not seen anywhere that dietitians are valid providers of this service. Can anyone help me unravel WHO can bill for G0447 and under what circumstances. MLN matters does not address this directly...

Kim Kelly
 

suemt

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Kim, although I'm not sure this is any clearer, from National Coverage Determination (NCD) for Intensive Behavioral Therapy for Obesity (210.12):

For the purposes of this decision memorandum a “primary care physician” and “primary care practitioner” will be defined consistent with existing sections of the Social Security Act (§1833(u)(6), §1833(x)(2)(A)(i)(I) and §1833(x)(2)(A)(i)(II)).
§1833(u)
(6) Physician Defined.—For purposes of this paragraph, the term “physician” means a physician described in section 1861(r)(1) and the term “primary care physician” means a physician who is identified in the available data as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.
§1833(x)(2)(A)
Primary care practitioner—The term “primary care practitioner” means an individual—
(i) who—
(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5))
 
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Billing for Obesity Counseling

Sue,

Thanks for the response. My bias is as yours that the rules for this are either a physician or provider (NP, PA, CNS) It is my understanding that while dietitians are 'providers' for Medical Nutrition therapy, that "providerness" does not extend to Obesity counseling (even though they may do a better job than a physician...). The nuance that I had not hear before was that the dietitian would contract with the physician office [thereby being an 'employee'] and provide the obesity counseling 'incident to' the physicians plan, the physician then submitting for payment. If you have heard of this or have any other perspective I would greatly appreciate it as I have seen it on more than one occasion, and a dietitian delivering a CE program told the group this 'was their way around not being listed as a provider for this service'.

Kim
 

suemt

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Kim, I'm doing some research on this for a project and I'm finding confusing and conflicting information, especially for non-governmental payors.

I welcome info from anyone who can either explain how the different insurance companies want to see this reported, or who has actually gotten paid for delivering these services to their patients.
 

suemt

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This is what I found for CIGNA: http://www.cigna.com/assets/docs/health-care-professionals/807467_d_PreventiveHealthCovGuide_v8_HR.pdf

and

http://www.cigna.com/assets/docs/about-cigna/839376_HCR_Preventive_Care_Fact_Sheet_v2.pdf


Can someone review and tell me if I'm reading this right? It looks to me like they want the initial obesity screening to be reported using the 993xx codes, and then the counseling to be reported using the 9940x codes (of course, with the corresponding diagnosis codes).

Although, if you look on page 8, the counseling codes are 9780x (but maybe this is because they will pay for non-physicans to provide these services?)
 
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Not clear on this yet

Suemt,

I read the Cigna pamphlet which seems to indicate the use of the G code for obesity counseling. What it DIDN"T say was who could do it. I know dietitians are dying to use this code to augment their retinue of reimbursable services, but I can't find anywhere that this is OK. I am pleased that you are looking in to this. Please let me know if you find anything!

Kim
 

suemt

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Some insight I received from a UHC person (at an AAPC meeting!) was that the insurer can say anything they want in these 'guideline' documents, but the individual plans are what govern. She said as far as they are concerned, this is all under weight management, and unless the individual plan is paying for Weight Watchers meetings and gym memberships, they are not likely to cover this at all.

I'm not convinced, but as you probably know, unless you are working for a specific provider, with a specific patient, you can't get access to individual plan details (and even THEN the insurance company doesn't always give you a straight answer!)

I'm surprised we haven't heard from anyone else on this.
 
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I actually researched this same issue several months ago. Interestingly, I learned that Medicare wants the nutritionists to perform the service. See the following link
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/mps_guide_web-061305.pdf (pages 126 and 127)

HOWEVER, I learned that Medicaid (in the state of Georgia) wants the physician/midlevel to perform the service.

And, I looked at Coding Clinic and found the following definition:

New Code for Behavioral Counseling for Obesity

HCPCS code G0447, Face-to-face behavioral counseling for obesity, 15 minutes, was created effective for dates of service on or after November 29, 2011. This service should be reported for Medicare beneficiaries with obesity. Beneficiaries must be considered competent and alert when the counseling is provided and the counseling must be provided by a qualified primary care physician or other primary care practitioner. HCPCS code G0449, which was previously used to report obesity screening, has been deleted effective November 29, 2011. CMS will provide additional coding and billing instructions for this new counseling code in a future Change Request.

It does sound like the code is specific to payer, and each payer would need to be contacted. GRrrrr - who has time to do that????????????????
 

mmoroney

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Medicare also indicates for G0447...
"Note: In addition, Medicare may cover behavioral counseling for obesity services when billed by the one of the provider specialty types listed above and furnished by auxiliary personnel under the conditions specific under our regulation at 42 CFR Section 410.26(b) (conditions for services and supplies incident to a physician's professional service) or 42 CFR Section 410.27 (conditions of outpatient hospital services and supplies incident to a physician service)."

The specialty codes Medicare list include general practice, family practice, internal medicine, ob/gyne, pediatrics, geriatrics, NP, CNS and PA.

Therefore, if auxillary personnel (i.e. nutrionist, dietician, etc.) perform the service, it may be billed incident to the provider's service...as long as the incident to guidelines are met.
 
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