Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)

For services furnished on or after November 29, 2011, Medicare will cover Intensive Behavioral Therapy for Obesity. Medicare beneficiaries with obesity (BMI ≥30 kg/m2 ) 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 in a primary care setting are eligible for:

• One face-to-face visit every week for the first month;

• One face-to-face visit every other week for months 2-6;

• One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement during the first 6 months as discussed below.

The counseling sessions are to be completed based on the 5As approach adopted by the USPSTF. The steps to the 5As approach are listed below:

1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

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 patient’s interest in and willingness to change the behavior.

4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/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 referral to more intensive or specialized treatment.

Medicare will cover Face-to-Face Behavioral Counseling for Obesity, 15 minutes (G0447), Face-to-face behavioral counseling for obesity, group (2-10), 30 minute(s) (G0473), along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30-V85.39 and V85.41-V85.45), up to 22 sessions in a 12-month period for Medicare beneficiaries. The Medicare coinsurance and Part B deductible are waived for this preventive service.

NOTE: Effective for claims with dates of service on or after January 1, 2015, codes G0473 and G0447 can be billed for a total of no more than 22 sessions in a 12-month period.

Contractors shall note the appropriate ICD-10 code(s) that are listed below for future implementation. Contractors shall track the ICD-10 codes and ensure that the updated edit is turned on when ICD-10 is implemented.

See Pub. 100-03, Medicare National Coverage Determinations Manual, §210.12 for complete coverage guidelines.

• Pub 100-04 Medicare Claims Processing Manual - Chapter 18

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