Improve the chances of your Medicare claims for obesity counseling

The most recent issue of the Medicare Quarterly Provider Compliance Newsletter said that documentation for obesity counseling has led to numerous instances of overpayment and other errors. Here’s what you need to know to ensure your documentation passes muster in an audit.

First, Medicare covers and pays for behavioral counseling for beneficiaries with obesity, measured as a body mass index (BMI) of 30 kg/m2 or greater. Specifically, obese Medicare beneficiaries 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 achieves the required weight loss.

Per Medicare, beneficiaries must be competent and alert at the time that they receive counseling, and the counseling must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Additionally, at the six-month visit, the beneficiary should receive a reassessment of obesity and a determination of the amount of weight loss. To be eligible for additional face-to-face visits occurring once a month for during months 7-12, beneficiaries must achieve documented weight loss of at least three kilograms (6.6 lbs.) during the first six months of intensive therapy.

Obesity counseling is reported with Healthcare Common Procedure Coding System (HCPCS) code G0447, “Face-to-face behavioral counseling for obesity, 15 minutes.” Medicare reviewers conducted a special study of HCPCS code G0447. Upon review, they determined that insufficient documentation caused approximately 92 percent of the improper payments. Examples of “insufficient documentation” included:

•    No physician’s signature on the encounter note
•    No documentation of the patient’s clinical condition
•    No documentation that the beneficiary has a BMI greater than or equal to 30kg/m2
•    No documentation that after six months the beneficiary lost 6.6 pounds or 3kg
•    No documentation that obesity counseling and dietary assessment actually occurred

So, to help improve the chances that your claims for obesity counseling will stand up to Medicare scrutiny, you need to document the patient’s clinical condition and qualifying BMI. You also need to document how much weight the patient has lost at the six-month mark and the counseling and dietary assessment that occurred at each visit. Finally, don’t forget to sign the encounter note when you’re done.

Medicare covers intensive behavioral therapy for obesity per National Coverage Determination 210.12. You can learn more about this benefit and the associated rules by reading section 200 of chapter 18 in the Medicare Claims Processing Manual as well as the Medicare Learning Network Matters article on obesity counseling.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians