Blue Shield Federal and Obesity/Dietary counseling gets very specific

My first post on obesity counseling can be found here. This is a very specific update to help you get paid a bit more. 

 

I have been running into problems with certain insurances. They have been bundling and excluding my G0447 and 99401 codes even though I am following my own guide. Blue Shield Federal and some Aetna plans are the most common offenders. Lengthy and boring story condensed, and, it turns out, these plans have specific exclusions for the diagnosis of Z68.30 to Z68.45. 

 

When I bill the claim with the Z code primary, the code gets denied stating the service is not a benefit. When I bill the claim with either E66.01 or E66.09 on the obesity counseling line item, and leave off the Z code entirely, those line items get paid. 

 

I also really suggest that if your system has pop-ups, alerts, built in claims edits, or anything along those lines that you utilize those for these specific situations. I know, personally, there is no way that I will be able to remember which specific patients or plans need these special rules without that tool. I do enough follow up as it is, I am not trying to make more for myself.  

 

One of the things that people often hire me for is an in-depth consult of an entire practice reviewing reports, procedures, and EOBs to help you make sure that you are keeping this type of money in your practice. I also have group and one-on-one training sessions to teach billers and managers how to do this themselves. Call me at (909) 610-9524 or email me at newgenerationbilling@gmail.com if you want to set something up.  

How to get a fat check for your obesity counseling.

Full disclosure, I am not that funny. That title was suggested to me and it was too good not to use.

Moving on.

Insurances have come a long way in the last 15 years. Even the best PPO plans in 2003 wouldn’t pay for “weight loss” even for morbidly obese patients. Patients had to jump through hoops to get mental health services and your insurance probably still laughs at you if you need chiropractic or acupuncture. 

However, insurances have started to realize that weight management, mental health, and pain management without addiction are vital to a patient’s overall health. Many insurances have incentivized obesity reduction , both with fee for service payments, and bonuses, as part of a focus on a patient’s health, rather than their illness. 

Insurances differ, though, on HOW they are going to pay for obesity counseling. Many offices end up not receiving their proper reimbursement because each insurance company wants the service reported a different way. This guide will help you get paid for your obesity counseling in addition to your regular office visit. 

All insurances will only pay for obesity counseling if the patient has a BMI over 30. If the patient’s BMI is under that, but they are still overweight, by all means please continue to help them bring their weight to a healthy level, but you won’t be reimbursed separately. Also, see the disclaimer at the bottom of the article please. 

Medicare and Medi-Cal – Use the Z-code for BMI as the primary diagnosis on the line item and use CPT code G0447. Put a 25 modifier on your office visit.  

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32                                                                  G0447

I am not sure if the Medicaid programs in other states will pay for obesity counseling, I know they will in California. 

Blue Cross, Blue Shield, Aetna, Cigna, Health Net PPO/MC/EPO plans – Use the Z-code for BMI as the primary diagnosis on the line item and use CPT code 99401. Put a 25 modifier on your office visit. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32                                                                  99401

Not all Health Net plans or BlueCross Blue Shield plans pay for obesity counseling, but most of them are coming out of the dark ages. 

United HealthCare Commercial PPO/MC – Use the E-Code for morbid obesity as the primary diagnosis on the line item. Use the Z-code for BMI as the secondary diagnosis on the line item and use CPT code 99401. Put a 25 modifier on your office visit. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                E66.01          Z68.32                                              99401

United HealthCare Medicare Advantage plan – Use the E-Code for morbid obesity as the primary diagnosis on the line item. Use the Z-code for BMI as the secondary diagnosis on the line item and use CPT code G0447. Put a 25 modifier on your office visit and a 59 modifier on the G0447.

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                E66.01          Z68.32                                              G0447           59

HMO Plans – It’s capped. Do whatever you want. If you have a fee for service contract, the 99401 usually gets paid a little more than the G0447, so I suggest you use the format for the regular commercial plans. 

                   DX                DX2                 DX3                        CPT            Modifier

                   I10              E11.9               M54.5                     99214            25

                 Z68.32          E66.01                                             99401

Some senior plans will give providers a bonus for treating patients with more severe diagnosis. Not a fee for service bonus, but a quarterly bonus. So, also add the appropriate E-code to help your doctor increase their score. 

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Here is the disclaimer. One of my favorite things to remind you is that in the billing world, the rules change every 10 minutes. So, if you are reading this in 2020, there may be different regulations to follow. Email me. 

Also, if you are billing the obesity counseling with any other type of counseling, you will probably have to be quite liberal with the 59 modifiers in order to get each line item paid separately. In fact, if my doctor does an obesity counseling and a smoking cessation counseling, I will switch the 99401 to a G0447 for the commercial plans (UHC is the exception) so it doesn’t get bundled. Blue Cross requires a 25 modifier on the G0447 if you bill it that way. 

If you want me to help you by reviewing a couple of your claims for the correct coding, I will be happy to do that. 

As always, call (909) 610-9524 or email newgenerationbilling@gmail.com with questions or to schedule an online training seminar.