Monday, September 28, 2015

Medicare CPT code G0447, G0473 Guidelines

CPT CODE AND Description

G0447
- Face-to-face behavioral counseling for obesity, 15 minutes

G0473 - Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

Be sure your staffs are aware of this new coverage determination and that Healthcare Common Procedure Coding System (HCPCS) code G0447 (Face-to-Face Behavioral Counseling for Obesity, 15 minutes) will be used to bill for these services. This code was effective November 29, 2011, and will appear in the January 2012 quarterly update of the Medicare Physician Fee Schedule Database (MPFSDB) and the Integrated Outpatient Code Editor (IOCE).


Diagnostic Codes

Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes. G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45). The type of service (TOS) for G0447 is


1. (ICD-10 codes will be Z68.30-Z68.39, Z68.41- Z68.45)

Effective for claims with dates of service on or after November 29, 2011, Medicare contractors will deny claims for HCPCS G0447 that are not submitted with the appropriate diagnostic code (V85.30-V85.39, V85.41-V85.45).

Claims submitted with HCPCS G0447 that are not submitted with these diagnosis codes will be denied with the following messages:

• Claim Adjustment Reason Code (CARC) 167 – "This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

• Remittance Advice Remark Code (RARC) N386 – "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp

• Group Code PR (Patient Responsibility), assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file).


. If you do not have web access, you may contact the contractor to request a copy of the NCD." • Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).


Preventive and Screening Services— Update - Intensive Behavioral Therapy for Obesity Associated with Screening Colonoscopy 


An update from the Centers for Medicare & Medicaid Services (CMS) to ensure accurate program payment for three screening services. The coinsurance and deductible for these services are currently waived, but due to coding changes and additions, the payments for Calendar Year (CY) 2015 would not be accurate without updated CR8874 for intensive behavioral group therapy for obesity, digital breast tomosynthesis, and anesthesia associated with screening colonoscopy.

Be sure your staffs are aware of this new coverage determination and that Healthcare Common Procedure Coding System (HCPCS) code G0447 (Face-to-Face Behavioral Counseling for Obesity, 15 minutes) will be  used to bill for these services.

 This code was effective November 29, 2011, and will appear in the January 2012 quarterly update of the Medicare Physician Fee Schedule Database (MPFSDB) and the Integrated Outpatient Code Editor (IOCE).

The following outlines the CMS updates:

Intensive Behavioral Therapy for Obesity

Intensive behavioral therapy for obesity became a covered preventive service under Medicare, effective November 29, 2011. It is reported with HCPCS code G0447 (Face-to-face behavioral counseling for obesity, 15 minutes). Coverage requirements are in the “Medicare National Coverage Determinations(NCDs) Manual,” Chapter 1, Section 210. Intensive Behavioral Therapy for Obesity To improve payment accuracy, in CY 2015 Physician Fee Schedule (PFS) Proposed Rule, CMS created a new HCPCS code for the reporting and payment of behavioral group counseling for obesity --HCPCS codes G0473 (Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes).


For coverage requirements of intensive behavioral therapy for obesity, see the NCD for Intensive Behavioral Therapy for Obesity. 

The same claims editing that applies to G0447 applies to G0473. Therefore, effective for claims with dates of service on or after January 1, 2015, MACs will recognize HCPCS code G0473, but only when billed with one of the ICD-9 codes for Body Mass Index (BMI) 30.0 and over (V85.30,-V85.39, V85.41-V85.45). (Once ICD-10 is effective, the related ICD-10 codes are Z68.30-Z68.39 and Z68.41-Z68.45.) When claims for G0473 are submitted without a required diagnosis code, they will be denied using the following remittance codes:

•Claim Adjustment Reason Code (CARC) 167: This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

•Remittance Advice Remarks Code (RARC) N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at w.cms.mcd.search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.


Effective for claims with dates of service on or after January 1, 2015, beneficiary coinsurance and deductible do not apply to claim lines with HCPCS code G0473.

Note that Medicare pays claims with code G0473 only when submitted by the following
provider specialty types as found on the provider's Medicare enrollment record:

• 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

Claim lines submitted with G0473, but without an appropriate provider specialty will be denied with the following remittance codes:

• CARC 8: The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

• RARC N95: This provider type/provider specialty may not bill this service.

• Group Code CO (if GZ modifier present) or PR (if modifier GA is present).

Further, effective for dates of service on or after January 1, 2015, claim lines with G0473 are only payable for the following Places of Service (POS) codes:

• 11 - Physician’s Office
• 22 - Outpatient Hospital
• 49 - Independent Clinic
• 71 - State or local public health clinic

Claim lines for G0473 will be denied without an appropriate POS code using the following remittance codes:

• CARC 5:The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

•RARC M77: Missing/incomplete/invalid place of service.

•Group Code CO (if GZ modifier present) or PR (if modifier GA is present).


Remember that Medicare will deny claim lines billed for HCPCS codes G0447 and G0473 if billed more than 22 times in a 12-month period using the following codes:

•CARC 119: Benefit maximum for this time period or occurrence has been reached.

•RARC N362: The number of days or units of service exceeds our acceptable maximum.

•Group Code CO (if GZ modifier present) or PR (if modifier GA is present).

Note: MACs will display the next eligible date for obesity counseling on all MAC provider inquiry screens.

MACs will allow both a claim for the professional service and a claim for a facility fee for G0473 when that code is billed on type of bill (TOB) 13X or on TOB 85X when revenue code 096X, 097X, or 098X is on the TOB 85X. Payment on such claims is based on the following:

• TOB 13X paid based on the OPPS:

• TOB 85X in Critical Access Hospitals based on reasonable cost; except

• TOB 85X Method II hospitals based on 115 percent of the lesser of the fee schedule amount or the submitted charge.  Institutional claims submitted on other than TOB 13X or 85X will be denied using:

• CARC 171: Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

• RARC N428: Not covered when performed in this place of service.

• Group Code CO (if GZ modifier present) or PR (if modifier GA is present).


Billing And Coding Guidelines.


Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes. G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45). The type of service (TOS) for G0447 is 1. (ICD-10 codes will be Z68.30-Z68.39, Z68.41- Z68.45) Effective for claims with dates of service on or after November 29, 2011, Medicare contractors will deny claims for HCPCS G0447 that are not submitted with the appropriate diagnostic code (V85.30-V85.39, V85.41-V85.45).


Specialty Codes

Effective for services on or after November 29, 2011, Medicare will pay claims for G0447, only when services are submitted by the following provider specialty types found on the provider’s Medicare enrollment record:

• 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


Place of Service (POS) Codes

Effective for services on or after November 29, 2011, Medicare will pay for obesity counseling claims containing HCPCS G0447 only when services are provided with the following POS codes:

• 11 - Physician’s Office

• 22 - Outpatient Hospital

• 49 - Independent Clinic

• 71 - State or local public health clinic.



Frequency Limitation

Effective July 2, 2012, for claims processed with dates of service on or after November 29, 2011, Medicare will pay for G0447 with an ICD-9 code of V85.30- V85.39, V85.41-V85.45, no more than 22 times in a 12-month period. Line items on claims beyond the 22 limit will be denied using the following codes: (Note: When applying this frequency limitation, a claim for the professional service and a  claim for a facility fee will be allowed.)


Institutional Claims Notes

Claims submitted with either a Type of Bill (TOB) 13X or TOB 85X (where the revenue code is not 096X, 097X, or 098X) will be identified as facility fee service claims.

Claims submitted with TOBs 71X, 77X, or 85X (where the revenue code is 096X, 097X, or 098X) will be identified as professional service claims. Medicare will pay for G0447 on institutional claims in hospital outpatient departments TOB 13X based on OPPS and in Critical Access Hospitals TOB 85X based on reasonable cost.

The CAH Method II payment is for G0447 with revenue codes 096X, 097X, or 098X is  based on 115% of the lesser of the fee schedule amount or submitted charge. Deductible and coinsurance do not apply. Medicare will line-item deny any claim submitted with G0447 when the TOB is not 13X, 71X, 77X, or 85X with the following:


• CARC 5 - "The procedure code/bill type is inconsistent with the Place of Service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

• RARC M77 - "Missing/incomplete/invalid place of service."

• Group Code PR (Patient Responsibility), assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file) and

• Group Code CO (Contractual Obligation), assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file)


Overview

This policy describes Optum’s requirements for the reimbursement and documentation of “Obesity Screening and Counseling in Adults” – CPT codes 99401 and 99402, and HCPCS procedure code G0447.

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.


These visits must be provided by a qualified health care provider.

Reimbursement Guidelines For eligible 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 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.
2

These visits must be provided by a qualified health care provider.

CPT codes for obesity screening and counseling are:

• 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 code for obesity screening and counseling is:

• G0447 – face-to-face behavioral counseling for obesity, 15 minutes – for billing for behavioral counseling for obesity


Coding Information

The CMS recognizes the HCPCS code G0447 – face-to-face behavioral counseling for obesity, 15 minutes – for billing for behavioral counseling for obesity.

The CPT codes most likely to be recognized by commercial payers are:

• 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.


Additional CPT and HCPCS codes for individual obesity screening and counseling that may be recognized by certain commercial payers include 97802–97804 (medical nutrition therapy), G0447 (face-to-face behavioral counseling for obesity, 15 minutes), or S9470 (nutritional counseling, dietitian visit). The application of these service codes may be subject to restrictions based upon provider type (e.g., dietitian), diagnosis (e.g., 307.1; anorexia nervosa) etc. [BCBS-MN, UHC]. Table 1 summarizes the diagnosis codes commonly associated with procedural codes for reporting screening for obesity in adults. The reporting of a related diagnosis code may be required by certain commercial payers (e.g., UHC) for billing procedural codes other than G0447.



Behavioral Counseling

G0447 Face-to-face behavioral counseling for obesity, 15 minutes $24 $26

G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes 12 13


Diagnostic Codes

G0447 and G0473 must be billed along with 1 of the ICD-10 codes for BMI 30.0 and over (Z68.30 - Z68.39, Z68.41 - Z68.45).


Additional Services on Same Date of Service

Obesity counseling is not separately payable with another encounter/visit on the same day. For services that contain HCPCS code G0447 with another encounter/visit with the same date of service, the service line with HCPCS G0447 will be denied. This intensive behavioral therapy service is considered to be included in the payment/allowance of other encounter services provided on the same date of service. This does not apply for Initial Preventative Physical Examination (IPPE) claims, claims containing modifier 59 indicating the obesity counseling as distinct from a significant and separate E/M service, and 77X claims containing Diabetes SelfManagement Training and Medical Nutrition Therapy services.



Additional Codes for Commercial Payers

The CMS recognizes G0447 and G0473 for billing for behavioral counseling for obesity only. The CPT and HCPCS codes most likely to be recognized by commercial payers are as follows.

CPT Code3      Procedure   Nat Average Facility Medicare Payment   Nat AverageNon-Facility  Medicare Payment

Behavioral Counseling

97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes $33 $35

97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 28 30

97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes 15 16

99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes 25 37

99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes 50 62

G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes 28 30

G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals),  each 30 minutes 15 16

S9452 Nutrition classes, nonphysician provider, per session Carrier Priced Carrier Priced  S9470 Nutritional counseling, dietitian visit Carrier Priced Carrier Priced


Effective July 2, 2012, for claims processed with dates of service on or after November 29, 2011, Medicare will pay for G0447 with appropriate ICD-9 code no more than 22 times in a 12-month period. Effective January 1, 2015, for claims processed with dates of service on or after January 1, 2015, Medicare will pay for G0447 and G04735 with appropriate ICD-9 code (ICD-10-CM code beginning October 1, 2015) no more than 22 times in a  12-month period.

Medicare coinsurance and Part B deductible are waived for this service.

Remittance Advice Notices.--

A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is under 50 years of age, use existing American National Standard Institute (ANSI) X12-835 claim adjustment reason code 6 “the procedure code is inconsistent with the patient’s age,” at the line level along with line level remark  code M82 “Service is not covered when beneficiary is under age 50.”

B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the time period between the test/procedure has not passed, use existing ANSI X12-835 claim adjustment reason code 119 “Benefit maximum for this time period has been reached” at the line level.

C. If the claim is being denied for a screening colonoscopy (code G0105) or a screening barium enema (G0120) because the beneficiary is not at a high risk, use existing ANSI X12-835 claim adjustment reason code 46 “This procedure is not covered” at the line level along with line level  remark code M83 “Service is not covered unless the beneficiary is classified as a high risk.”

D. If the service is being denied because payment has already been made for a similar procedure within the set time frame, use existing ANSI X12-835 claim adjustment reason code 18, “Duplicate claim/service” at the line level along with line level remark code M86 “This service is denied because payment has already been made for a similar procedure within a set  timeframe.”

E. If the claim is being denied for a noncovered screening procedure such as G0122, use existing ANSI X12-835 claim adjustment reason code 49, “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.”

Diagnostic Codes

Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes. G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45). The type of service (TOS) for G0447 is 1. (ICD-10 codes will be Z68.30-Z68.39, Z68.41- Z68.45) Effective for claims with dates of service on or after November 29, 2011, Medicare contractors will deny claims for HCPCS G0447 that are not submitted with the appropriate diagnostic code (V85.30-V85.39, V85.41-V85.45).

Claims submitted with HCPCS G0447 that are not submitted with these diagnosis codes will be denied with the following messages:

• Claim Adjustment Reason Code (CARC) 167 – "This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

• Remittance Advice Remark Code (RARC) N386 – "This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp

• Group Code PR (Patient Responsibility), assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file). . If you do not have web access, you may contact the contractor to request a copy of the NCD."


• Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).



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