Bariatric Times

Insights into Patient Pop with Obesity 2016

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Bariatric Times • December 2016 • Supplement C C19 System (HCPCS) code and corresponding ICD-10-CM diagnosis code, using the XI-2-837-1 (Institutional) electronic claim format. The Types of Bill (TOB) allowed for institutional claims include: hospital outpatient, rural health clinic (RHC), federally qualified health center (FQHC), and critical access hospital (CAH). Coding information differs by institution as well. Face-to-face behavioral counseling for obesity should be coded as G0447 with the appropriate ICD-10-DM Diagnosis Code for BMI 30.0kg/m 2 or higher (V85.30- V85.39, V85.41, V85.451). Do not use 278.00 or 278.01 for coding, and there is no need to add a comorbid diagnosis. Use preventative codes (99401 to 99404 as mandated by the Affordable Care Act [ACA]) for follow up and management, respectively. IBT for obesity can be reimbursed when it is provided by an auxiliary staff member, such as a nurse practitioner (NP) under direct supervision of the physician. This can be an efficient, effective, and cost-effective way to deliver IBT for obesity in a busy primary care practice. Physicians and other specialties may be compensated for IBT if they have multiple credentials and bill under the approved taxonomy codes (e.g. NP or PA [physician's assistant]). Payment for IBT for obesity is made by way of electronic funds transfer (EFT), which must be set up in advance. For professional claims, Medicare pays for IBT for obesity under the Medicare Physician Fee Schedule (MPFS), but as with other MPFS services, non- participating provider reduction and limiting charge provisions apply for all IBT for obesity services. Institutional claims for IBT for obesity are made based on the type of facility (hospital outpatients, RHC, FQHC, CAH). For hospital outpatients, payment for IBT for obesity is made by the outpatient prospective payment system (OPPS). For RHC and FQHC, payment is made at the all-inclusive payment rate. For CAH, there are two methods of payment. The first method pays 101 percent of reasonable costs for the technical component(s) of services while the second method pays 101 percent of reasonable costs for the technical component(s) of services plus 114 percent of the MPFS non-facility rate for professional component(s) of services. Claim denials for IBT for obesity are most often made because the beneficiary received more than the allowed 22 IBT sessions for obesity in the past 12 months or because the beneficiary received IBT for obesity outside of the primary care setting. Despite these major advances in reimbursement for IBT for obesity, fewer than one percent of those patients eligible for IBT benefits actually receive them. Possible reasons for this shortfall may include the fact that many PCPs and their patients are unaware that this treatment (IBT) and benefit (reimbursement) are available to them. Another possible reason is that some physicians may be aware of reimbursement but not offer IBT because they lack specific training or feel they would not be equipped to manage this type of care. Table 4. Requirements for IBT for Medicare Coverage 44 ELIGIBLE BENEFICIARIES QUALIFIED PCPS ALLOWABLE VISITS ALLOWABLE PC SETTINGS BMI>30 Physician with primary specialty of family practice, Maximum of 22 IBT sessions for obesity in 12 mo Independent clinics Competent and alert during counseling Qualified non-physician 1 face-to-face visit every week for first mo Outpatient clinics Must lose 3 kg in first 6 mo to continue coverage Auxiliary personnel, such as registered dieticians working for one of the provider specialty 1 face-to-face visit every other week for months 2-6 Physician offices 1 face-to-face visit every mo for months 7-12 if the beneficiary loses at least 3 kg in first 6 mo State or local public health clinics BMI: body mass index; kg: kilogram; mo: month; PC: primary care; PCP: primary care provider Insights into the Patient Population with Obesity: Assessment and Treatment u

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