NOTE: All FQHCs are paid under the FQHC prospective payment system (PPS) for primary health services and qualified preventive health services. FQHCs are paid for the professional component of qualified preventive services under the PPS when all of the program requirements are met and frequency limits have not been exceeded.
Intensive Behavioral Therapy (IBT) for Obesity
Effective for claims with dates of service on November 29, 2011, and later, The Center for Medicare and Medicaid Services (CMS) released a decision memo stating “the evidence is adequate to conclude that intensive behavioral therapy for obesity, defined as a body mass index (BMI) ³ 30 kg/m2, is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF).”
Intensive behavioral therapy for obesity consists of the following:
Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2);
Dietary (nutritional) assessment; and
Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high-intensity interventions on diet and exercise.
Primary Care Physician
To be reimbursed, the intensive behavioral intervention counseling must be provided by one of the following provider specialty types:
• General Practice
• Family Practice
• Internal Medicine
• Pediatric Medicine
• Geriatric Medicine
• Nurse Practitioner
• Certified Clinical Nurse Specialist
• Physician Assistant
This counseling is not the same as the pre-operative psychiatric evaluation Bariatric surgery candidates must undergo. In addition, Medicare may cover behavioral counseling for obesity services when billed by one of the provider specialty types listed above and furnished by auxiliary personnel under the conditions specified under CMS regulation 42 CFR Section 410.26(b) - Conditions for services and supplies incident to a physician’s professional service, or 42 CFR Section 410.27 - Conditions for outpatient hospital services and supplies incident to a physician service.
For the purpose of this national Medicare coverage determination, the acceptable setting of care and primary care physician has been defined. The recommendations are for the intensive behavioral therapy to be administered in one of the following acceptable places of service:
• Physician’s Office
• Outpatient Hospital
• Independent Clinic
• State or local public health clinic
For Medicare beneficiaries with obesity, 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 and in a primary care setting, CMS covers:
• One (1) telehealth visit every week for the first month [four (4) sessions];
• One (1) telehealth visit every other week for months two through six [ten (10) sessions];
• One (1) telehealth visit every month for months seven through twelve [six (6) sessions], if the beneficiary meets the 3kg (6.6-lbs) weight loss requirement as discussed below...
At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg (6.6-lbs) over the course of the first six months of intensive therapy. This determination must be documented in the physician’s office records for applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight loss of at least 3kg (6.6-lbs) during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six-month period.
G0447 Face-to-face behavioral counseling for obesity, 15-minutes $ 25
G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30-minutes $12