Intensive Behavioral Therapy for Obesity

As required by the Centers for Medicare & Medicaid Services (CMS), Health Net covers screenings for obesity and counseling by primary care physicians (PCPs) without cost-share for eligible members.

Assessment

Medicare members with obesity, defined as a body mass index (BMI) equal to or greater than 30 kg/m² (weight in kilograms divided by the square of height in meters), who are competent and alert at the time counseling is provided and whose counseling is furnished by a qualified PCP in a primary care setting, are eligible for:

1. One face-to-face visit every week for the first month.
2. One face-to-face visit every other week for months two to six.
3. One face-to-face visit every month for months 7-12, if the beneficiary meets the 3 kg (6.6 lb.) weight-loss requirement during the first six months.

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

Reassessment

At the six-month visit, the provider should reassess the member and determine the amount of weight loss. To be eligible for additional face-to-face visits occurring once a month for months 7-12, members must have lost at least 3 kgs (6.6 lbs.) over the course of the first six months of intensive therapy. Providers must document this determination in members' medical records consistent with usual practice.

If the member has not met the 3 kg weight-loss requirement during the first six months, they are not eligible for continuing monthly visits. However, after an additional six months, the member is eligible for a reassessment of their BMI and readiness to change.

Intensive behavioral therapy (IBT) Components

IBT for obesity consists of the following:

1. Screening for obesity in adults using the measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed kg/m2).
2. Dietary (nutritional) assessment.
3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high-intensity diet and exercise interventions.

Intensive behavioral intervention for obesity should be consistent with the following:

1. Assess - Assess behavioral health risk(s) and factors affecting choice of behavior change methods or goals.
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 member's interest in and willingness to change the behavior.
4. Assist - Using behavior change techniques (such as self-help or counseling), aid the member in achieving agreed-upon goals by acquiring the skills, confidence and social or 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 offering referral to more intensive or specialized treatment, as necessary.

Billing Requirements

Providers must submit claims, with the following HCPCS or ICD-10, and place-of-service codes. If the claim does not include this information, it is denied.

Frequency Limitation

Medicare pays for G0447 with an ICD-10 code of Z68.30 - Z68.39 or Z68.41 - Z68.45, no more than 22 times in a 12-month period. Line items on claims beyond the 22^nd time are denied using the following codes:

1. CARC 119 - Benefit maximum for this time period or occurrence has been reached.
2. RARC N362 - The number of days or units of service exceeds our acceptable maximum.
3. Group code PR (patient responsibility), assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed advance beneficiary notice of non-coverage (ABN) is on file).
4. 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).

When applying this frequency limitation, a claim for the professional service and a claim for a facility fee are allowed.