Billing and coding in obesity medicine

Though similar to other specialties, some billing codes are unique for behavioral therapy.

Coding in obesity medicine is much like coding in any other outpatient specialty. There are the standard outpatient E&M codes (99204/99214) which are for the typical new or established patient and also cover pharmacotherapy—such as prescribing phentermine or Saxenda—and chronic care medications. There are, however, some billing codes unique to obesity medicine for behavioral therapy. This is where billing and coding becomes especially important.

Preventative Counseling: 99401-99412

The standard obesity medicine behavioral counseling codes are 99401-99412. These codes are used to report services for the purpose of promoting health and preventing illness. Typically, the 5-A’s approach—ask, advise, assess, assist, and arrange—is used. More specific counseling techniques such as motivational interviewing and cognitive behavior therapy may also be employed. These codes are time-based with increments of 15 minutes and cover both individual and group counseling. The wording pertaining to the time requirement states they require approximately 15 minutes. In time-based codes that do not specify “at least” a specific time, the 50 percent rule applies. So, counseling for at least 7.5 minutes codes to a 99401 (approximately 15 minutes), and 22.5 minutes codes to a 99402 (approximately 30 minutes).

Reimbursement for 99401 is typically on the order of $30-40. While not a princely sum, this is typically a service done in addition to pharmacotherapy management. Apply a 25 modifier, denoting a separate service on the same visit, and this will earn an extra $35 on your standard 99214 reimbursement. Better yet, this coding subset is covered as a preventative service, so insurance pays the entire amount—no patient cost sharing is allowed. Medicare has its own separate code, G0447, which pays about 25 percent less and comes with more specific coding rules.

Health Behavior Assessment and Intervention Codes: 96156, 96158

These codes are similar to preventative service counseling, but they deal more with specific behavioral problems often encountered in an obesity medicine practice. These services “…are used to identify and address the psychological, behavioral, emotional, cognitive, and interpersonal factors important to the assessment, treatment, or management of physical health problems,” according to the American Psychological Association. Consider these codes for specific behavioral problems, such as addiction, eating disorders, and environmental conditions that cause eating problems. 96156 is an untimed code used for an assessment or reassessment of a behavioral condition, and it reimburses about three times more than a 99401 code.

CPT code 96158 is for behavioral intervention. While the code is for the initial 30 minutes of counseling, the 50 percent rule also applies. Be sure to document at least 16 minutes of therapeutic counseling. The code reimburses about twice as much as a 99401 code. There are also group codes, extended time codes, and codes for counseling the family without the patient present.

The next time you see your obesity medicine patient, remember to ask yourself: are you promoting a healthier lifestyle or are you providing counseling for a particular obesity related behavior that may qualify for a higher reimbursing code?

About the Author
Carl Knopke, MD, FOMA, FAAFP, is the medical director of Inland Empire Weight Loss in Riverside, California. He is board certified in Obesity Medicine and Family Medicine. He is an assistant professor of Family Medicine at the University of California Riverside School of Medicine and a member of the Board of Trustees for the Obesity Medicine Association (OMA). His primary medical interests include treating diabetes, hypertension, hyperlipidemia, and arthritis using the tenets of obesity medicine. He also has special interests in psychiatry, psychology and exercise physiology and how they can be applied to treat obesity.