01/24/14
Informational Notice
BMI Assessment and Obesity-related Weight Management
Follow-up among Children and Adolescents: Documentation and Claims Coding
Instructions
This notice is revised to clarify language in Section B. Body Mass Index
Assessment Documentation in Claims related to claiming ICD-9-CM codes 278.00 –
278.02 with ICD-9-CM codes V85.51 – V85.54.
The purpose of this notice is two-fold. First, to advise providers to report
assessment of Body Mass Index (BMI) percentile in claims submittals to HFS.
Second, this notice is to clarify the conditions under which weight management
Evaluation & Management (E&M) visits can be billed.
A. Clinical GuidelinesProviders are encouraged to
follow recommended clinical guidelines for evaluation & management of
overweight and obesity. In 2007, the American Medical Association (AMA)
published clinical recommendations for the prevention and treatment of
overweight and obesity (see
Barlow
SE; Expert Committee recommendations regarding the prevention, assessment,
and treatment of child and adolescent overweight and obesity; Summary report. In
2010, the U. S. Preventive Services Task Force released its recommendation on
screening for obesity (see Barton M; U.S.
Preventive
Task Force).
Primary Care Physicians and other providers are encouraged to routinely
assess and document children's weight status and weight trajectory and counsel
parents about how to help their children achieve and maintain a healthy weight.
The CDC's
Research
to Practice series, available through their Nutrition Resources for
Health Professionals Web page, provides information regarding the use of
therapeutic lifestyle changes, and guidance for encouraging modifications around
nutrition and physical activity.
The American Academy of Pediatrics'
Bright
Futures Guidelines for Health Supervision for Infants, Children, and
Adolescents, 3rd Edition, (2008) suggest that parents need information on
how to encourage their children and adolescents to practice healthy eating
behaviors, beginning in childhood. Bright Futures Guidelines and clinical
recommendations provide a set of recommendations for healthcare professionals to
assist families, which HFS subscribes to.
B. Body Mass Index Assessment Documentation in
ClaimsAnnually, HFS reports performance on a core set of child health
measures to the Centers for Medicare and Medicaid Services (CMS). One of these
measures reports the prevalence of weight assessment of children and adolescents
documented through claims. In accordance with expert committee recommendations
as referred to above, providers are encouraged to assess and document BMI
percentile at least one time per year for pediatric patients ages 2 through 20.
BMI assessment may be done during any visit, sick child or preventive.
Claims for an episode or encounter where BMI is assessed must include the
appropriate CPT or UB-04 revenue code,
and ICD-9-CM
codes V85.51 – V85.54. If ICD-9-CM codes V85.53 or V85.54 are used, then also
include ICD-9-CM code 278.00 – 278.02, as appropriate. Providers should append a
BMI-related diagnosis code for every episode or encounter of care during which
BMI was assessed, documented, and addressed, if indicated.
Documentation must include a note in the patient's record indicating:
- The date on which the BMI percentile was assessed
- One of the following measurements:
- BMI percentile, or
- BMI percentile plotted on age-growth chart
- If indicated, pertinent recommendation or plan of management consistent with
the codes used.
C. Weight Management Visits: BMI >85th
Percentile
- Providers may bill for weight management visits for children with BMI
>85th percentile; BMI percentile, as described above, must be measured and
documented during that visit.
- Visits addressing problem-focused care delivered by a physician or an
advance practice nurse or physician's assistant billing under a physician, may
be billed for care delivered and documented using evidence-based clinical
guidelines as described above.
- For those in the >85th percentile, payable weight management visits may
include a maximum of 3 visits spread over a course of six months; follow-up
visits after the initial one visit must include, in the patient's record, a note
addressing the patient's/parent's readiness to change and outcomes of
intervention to date.
- An appropriate CPT code or UB-04 revenue code, an appropriate five-digit
ICD-9 diagnosis code 278.00 through 278.02 and one of V85.53 or V85.54 codes
must be included on the claim form for each visit.
- Diagnosis codes for obesity related co-morbid conditions, if present and
addressed at that visit, need to be listed on the claim form for each visit.
- Each visit should include, in patient record, documentation of educational
handouts given, care plan and outcomes based on specific treatment and behavior
changes (e.g., nutrition, physical activity etc.) recommended and made,
compliance with past recommendations, results of screening laboratory tests,
reports of referrals and consultations if any, and time spent by provider with
patient and family during that visit.
- No further visits related to weight management will be payable after a
maximum of 3 visits over a six month period, unless improvement in BMI
percentile is evident based on the V85.5x codes submitted for that claim or
documentation of favorable outcome is appended to the claim.
D. Additional Notes on Payment Policies Related to Weight
Management
- Weight management visits cannot be billed on the same day as a Preventive
Medicine visit.
- Weight management counseling services can be billed as part of a
problem-focused E&M visit using CPT codes 99204-99205, if provided to a new
patient, or 99214-99215 if provided during a follow-up visit to an established
patient. CPT guidance on this topic allows for this provision when counseling
and/or care coordination dominates (more than 50%) face-to-face encounter time
with the patient and/or family. The extent of counseling and/or coordination of
care (time as well as content of care, coordination and counseling) must be
documented in the medical record.
Providers wishing to receive e-mail notification when new provider
information is posted by the department may register by visiting the
HFS Provider Releases and Bulletins
E-mail Notification Request web page.
Questions regarding this notice may be directed to the Bureau of
Comprehensive Health Services at 1-877-782-5565.
Theresa A. Eagleson, Administrator
Division of Medical Programs
