(Medicare Claims Processing Manual)

200 - Intensive Behavioral Therapy for Obesity (Effective November 29, 2011)  (Rev. 2421, Issued: 03- 07-12, Effective: 11 -29-11, Implementation: 03- 06-12, for non -shared system edits, 07- 02-12 for shared system edits, CWF provider screen .HICR, and MCSDT changes)   The United States Preventive Services Task Force (USPSTF) found good evidence that body mass index (BMI) is a reliable and valid indicator for identifying adults at increased risk for mortality and morbidity due to overweight and obesity.  It also good evi dence that high intensity counseling combined with behavioral interventions in obese adults (as defined by a BMI 30 kg/m2) produces modest, sustained weight loss.   200.1 - Policy  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  For services furnished on or after November 29, 2011, Medicare will cover Intensive Behavioral Therapy for Obesity.  Medicare beneficiaries with obesity (BMI 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 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;  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 as discussed below.   The counseling sessions are to be completed based on the 5As approach adopted by the United States Preventive Services Task Force (USPSTF.)  The steps to the 5As approach are listed below:   1. Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.  2. Advise :  Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.   3. Agree:  Collaboratively select appropriate treatment goals and methods based on the patients interest in and willingness to change the behavior.   4. Assist :  Using behavior change techniques (self -help and/or counseling), aid the patient in achieving agreed -upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.   5. Arrange:  Schedule follow -up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.  Medicare will cover Face -to-Face Behavioral Counseling for Obesity, 15 minutes (G0447), Face -to-face behavioral counseling for obesity, group (2- 10), 30 minute(s) (G0473), along with 1 of the ICD -9-CM codes for BMI 30.0- BMI 70 (V85.30- V85.39 and V85.41- V85.45), up to 22 sessions in a 12- month period for Medicare beneficiaries.  The Medicare coinsurance and Part B deductible are waived for this preventive service.   NOTE :  Effective for claims with dates of service on or after January 1, 2015, codes G0473 and G0447 can be billed for a total of no more than 22 sessions in a 12- month period.  A/B MACs (A) and (B) shall note the appropriate ICD -10-CM code(s) that are listed below for future implementation.  A/B MACs (A) and (B) shall track the ICD -10-CM codes and ensure that the updated edit is turned on when ICD -10 is implemented.                      See Pub. 100- 03, Medicare National Coverage Determinations Manual, 210.12 for complete coverage guidelines.  200.2 - Institutional Billing Requirements  (Rev. 3232, Issued: 04- 03-15, Effective: 01 -01-15, Implementation: 01- 05-15)  Effective for claims with dates of service on and after November 29, 2011, providers may use the following types of bill (TOB) when submitting HCPCS code G0447:  13x, 71X, 77X, or 85X.  Service line items on other TOBs shall be denied.  Effective for claims with dates of service on and after January 1, 2015, providers may use the following types of bill (TOB) when submitting HCPCS code G0473:  13x or 85X.  Service line items on other TOBs shall be denied.   The service shall be paid on the basis shown below:    Outpatient hospitals -  TOB 13X -  based on Outpatient Prospective Payment System (OPPS)    Critical Access Hospitals (CAHs) -  TOB 85X - based on reasonable cost    CAH Method II -  TOB 85X -  based on 115% of the lesser of the Medicare Physician Fee Schedule (MPFS) amount or actual charge as applicable with revenue codes 096X, 097X, or 098X.  ICD-10-CM Description  Z68.30   BMI 30.0 -30.9, adult  Z68.31  BMI 31.0 -31.9, adult  Z68.32  BMI 32.0 -32.9, adult  Z68.33  BMI 33.0 -33.9, adult  Z68.34  BMI 34.0 -34.9, adult  Z68.35  BMI 35.0-35.9, adult  Z68.36  BMI 36.0 -36.9, adult  Z68.37  BMI 37.0 -37.9, adult  Z68.38  BMI 38.0 -38.9, adult  Z68.39  BMI 39.0 -39.9, adult  Z68.41  BMI 40.0 -44.9, adult  Z68.42  BMI 45.0 -49.9, adult  Z68.43  BMI 50.0 -59.9, adult  Z68.44  BMI 60.0 -69.9, adult  Z68.45  BMI 70 or greater, adult   NOTE:   For outpatient hospital settings, as in any other setting, services covered under this NCD must be provided by a primary care provider.   200.3 - Professional Billing Requirements  (Rev. 3315, Issued: 08- 06-15, Effective: 01 -01-16, Implementation: 01- 04-16)  CMS will allow coverage for Face- to-Face Behavioral Counseling for Obesity, 15 minutes, (G0447), Face -to-face behavioral counseling for obesity, group (2- 10), 30 minute(s) (G0473),  along with 1 of the ICD -9 codes for BMI 30.0- BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when services are submitted by the following provider specialties found on the providers 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   Any claims that are not submitted from one of the provider specialty types noted above will be denied.  CMS will allow coverage for Face -to-Face Behavioral Counseling for Obesity, 15 minutes, (G0447), Face -to-face behavioral counseling for obesity, group (2- 10), 30 minute(s) (G0473), along with 1 of the ICD -9 codes for BMI 30.0- BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when submit ted with one of the following place of service (POS) codes:   11 - Physicians Office  19 - Off Campus -Outpatient Hospital  22 - On Campus -Outpatient Hospital  49 - Independent Clinic  71 - State or Local Public Health Clinic   Any claims that are not submitted with one of the POS codes noted above will be denied.   NOTE:   HCPCS Code G0447 is effective November 29, 2011. HCPCS Code G0473 is effective January 1, 2015.  200.4 - Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A/B MACs (A) and (B) shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for obesity counseling sessions:    Denying services submitted on a TOB other than 13X and 85X:   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.   MSN 16.2 -  This service cannot be paid when provided in this location/facility.   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).  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).  NOTE:   For modifier GZ, use CARC 50 and MSN 8.81.   Denying services for obesity counseling sessions HCPCS code G0473 or G0447 with 1 of the ICD -9-CM codes (V85.30- V85.39 or V85.41- V85.45) or with one of the ICD -10-CM codes (Z68.30- Z68.39 or Z68.41- Z68.45) when billed for a total of more than 22 sessions in the same 12 -month period:   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.  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   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).  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).  NOTE:   For modifier GZ, use CARC 50 and MSN 8.81.   Denying claim lines for obesity counseling sessions HCPCS code G0473 or G0447 without 1 of the appropriate ICD -9-CM codes (V85.30- V85.39 or V85.41- V85.45) or 1 of the ICD -10-CM codes (Z68.30-Z68.39 or Z68.41- Z68.45):   CARC 167 -  This (these) diagnosis(es) is (are) not covered.  Note: Refer to the ASC X12 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   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.  If you do not have web access, you may contact the contractor to request a copy of the NCD.  MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.   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).  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).  NOTE:  For modifier GZ, use CARC 50 and MSN 8.81.   Denying claim lines without the appropriate POS code:   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.