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CRACKING THE CODE:

What You Need to Know About CPT Codes
Before and After Bariatric Surgery


Published in January 2014 Issue             


ASMBS Insurance Committee Co-Chair, Helmuth Billy, MD


Understanding and using the correct Current Procedural Terminology (CPT) codes could mean the difference between payment and non-payment, which may adversely affect patient care. The American Medical Association (A.M.A.) is the source of CPT, the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. According to the A.M.A., CPT is maintained by its CPT Editorial Panel, which meets three times a year to discuss new and emerging technologies, as well as issues encountered with procedures and services in relation to CPT codes.

It is well recognized that access to bariatric and metabolic surgery can be difficult due to coverage policies that may unnecessarily delay or deny treatment or not cover certain healthcare services that could prove critical to successful patient outcomes. However, understanding the issues and the ins and outs of the CPT codes themselves may help you and your patients navigate the weight loss journey more effectively before and after surgery. The following is an overview of preventive medicine, diagnosis, procedure/service and counseling for surgeons and integrated health.

Preventive Counseling/Risk Factor Reduction Intervention (CPT 99401-99412)

Follow up care is critical to improved bariatric patient outcomes. Preventive medicine codes may be successfully used after surgery to obtain reimbursement for visits where counseling was done to prevent weight regain. However, use of these codes can be confusing and different insurance companies have different guidelines with respect to if and how they will compensate physicians for preventive medicine or risk factor reduction services.

Preventive Medicine CPT Code Example

A patient comes in for follow up behavioral and preventive counseling after sleeve gastrectomy. During the course of the evaluation he complains that his GERD has returned and is now bad enough to require OTC PPI therapy. You perform a problem-oriented evaluation, history, review of system and physical examination. The abnormality encountered (GERD) is significant enough to require additional work as key components of a problem-oriented evaluation and management (E/M) service. The E/M evaluation for GERD was performed in the process of performing a preventive medicine evaluation and management service. The appropriate Office/Outpatient code 99201- 99215 should also be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable Evaluation and Management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

Counseling Risk Factor Reduction and Behavior Change Intervention:
What Does the CPT Book Say?

New or Established Patient

These codes are used to report services provided face to face by a physician or other qualified healthcare professional for the purpose of promoting health and preventing illness or injury. They are distinct from E/M services that may be reported separately when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.

Preventive medicine counseling and risk factor reduction interventions will vary with age and should address such issues as family problems, diet and exercise, substance use, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter.

Behavioral change interventions are for persons who have behavior that is often considered an illness itself, such as tobacco use and addiction, substance abuse/misuse, or obesity. Behavior change services may be reported when performed as part of the treatment of condition(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness. Any E/M services reported on the same day must be distinct and time spent providing these services may not be used as a basis for the E/M code selection. Behavior change services involve specific validated interventions of assessing readiness for change and barriers to change, advising a change in behavior, assisting by providing specific suggested actions and motivational counseling and arranging for services and follow up.

Patient Protection and Affordable Care Act -- New Coverage for Prevention

In general, since the implementation of the Patient Protection and Affordable Care Act (PPACA) many previously denied preventive services are now covered services for the treatment of obesity, weight management, nutrition, and physical activity counseling. However, coverage and reimbursement for these services can depend on the type of provider submitting the claim, the procedure/service and diagnosis codes submitted, and the patient’s contract with the insurance company. Checking with each specific insurance payor is encouraged before initiating any extensive preventive service.

Screening and Counseling for Obesity and Counseling for Healthy Diet Now Covered

The suggested coding for obesity screening and counseling includes 97802-97804, 99078, 99401-99404, 99411-99412, G0447, G0449, or S9470 as prevention with 278.00
or 278.01.

The suggested coding for counseling for a healthy diet includes 99401-99404, 99411-99412, 99078, 97802-97804, S9452, G0447, S9470 as preventive with V65.3.

Some services provided during bariatric follow up might not be subject to the PPACA.

Diagnosis Codes

The physician determines if the patient meets the criteria to be classified as obese. If the patient meets those criteria, two specific obesity diagnosis codes may be used:

1. 278.00 Obesity, Unspecified

2. 278.01 Morbid Obesity

In addition to the two specific obesity codes, the provider may also bill for obesity or weight management counseling with routine diagnosis codes such as:

1. V65.3 Dietary Surveillance and Counseling

2. V70.0 Routine General Medical Examination at a Health Care Facility

The obesity diagnosis codes of 278.00, 278.01 and code V65.3 will cause claims to pay according to the illness portion of the patient’s contract. Insurance company contracts have benefits for illness-related services. If the claim is submitted with a routine medical exam code of V70.0, it will pay based on the routine benefits, if any, are provided by the patient’s contract. Some contracts exclude routine benefits.

Claims can be submitted for obesity, weight management, nutrition counseling etc. with the diagnosis of the underlying symptom that brought the patient to the provider. For example, the claim may be submitted with a diagnosis of elevated blood cholesterol, shortness of breath, or diabetes. These claims will process according to the medical illness benefit.

Procedure/Service Codes

Services for obesity/weight management counseling may be billed under E/M codes (99201-99215) provided that those services meet the components of an E/M service. These E/M codes are compatible with all causes, illness or routine related, and will pay according to the diagnosis submitted. Claims may also be submitted as preventive counseling (99401-99404). These codes, however, are often only compatible with routine
diagnosis codes (e.g. V70.0).

Claims submitted with these procedure/service codes and a routine diagnosis code are processed according to the patient’s preventive benefit, provided the patient has coverage for preventive services. If CPT codes 99401-99404 are submitted with a diagnosis of obesity (e.g. 278.00) the claim can be rejected because E/M services for the treatment of obesity (278.00) are rarely a covered benefit of most insurance plans. 

Medical nutritional therapy codes (97802, 97803, S9470) may be billed when counseling patients on obesity or weight management. These codes are compatible with any diagnosis but are most intended for illness or disease-related diagnoses such as obesity or diabetes.

Nutritionists, Dieticians and Other Providers

Licensed dieticians and licensed nutritionists can bill for procedure/service codes S9470, 97802, 97803, G0447, and G0449 for diagnosis codes other than eating disorders. Services provided by licensed dieticians and nutritionists submitted using the provider number of an eligible medical clinic or hospital will increase the possibility of reimbursement.  Submitting the claim in conjunction with the individual provider number or NPI of the licensed dietician or licensed nutritionist is also recommended.

Physical Activity

There are no procedure/service codes specifically for physical activity counseling. Providers typically bill counseling services for physical activity as an E/M service (99201-99215) provided that the counseling meets the components of an E/M service. There is no specific diagnosis code for physical activity counseling. Exercise classes (S9451) are
generally non-covered.

The provider may also submit codes for preventive counseling (99401-99404). These codes, however, are usually compatible with routine diagnosis codes (e.g., V70.0). Claims submitted with these procedure/service codes and a routine diagnosis code will process according to the patient’s preventive benefit, provided the patient has coverage for preventive services.

The CPT code book provides the following information: Risk factor reduction services are for patients without a specific illness, whereas behavior change interventions are for patients that have behavior that is often an illness itself. Extensive complete and accurate documentation in the medical record is essential if a practice is to have any chance of getting reimbursed for preventive services performed on the same day as a separate E/M service.  On these occasions the medical record must support a significant and separately identifiable E/M service provided in addition to the other E/M service (preventive medicine service) provided on the same day. Modifier 25 is required when a procedure or other service (preventive medicine or risk factor reduction service) is performed on the same day as a significant and separately identifiable E/M service.

Use of Preventive Medicine and Risk Reductions Codes During Routine Visit

When a bariatric patient comes into the office for a routine follow up visit and examination, preventive medicine codes or risk factor reduction services may be used to seek reimbursement for the time and effort put into those separate services. 

If during the follow-up appointment there is a significant new complaint (e.g., chest pain, vomiting or dysphagia) and, in some instances, a new or established chronic condition (e.g., hypertension or type 2 diabetes), the visit becomes a combination of preventive and problem-oriented care. As long as service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam and the appropriate office visit code (99201-99215) with modifier -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service,” attached to the problem-oriented service. It is also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between preventive and problem-oriented services.

Quite often the work associated with performing the history, examination and medical decision making for the problem-oriented E/M service (dysphagia, malabsorption, GERD) might overlap those performed as part of the comprehensive preventive service to a certain extent. Therefore, the E/M code reported for the problem-oriented service should be based on the additional work performed by the physician to evaluate that problem. An insignificant or trivial problem or abnormality that does not require performance of these key components should not be reported separately from the preventive medicine service.

Reporting Preventive and Problem-oriented Services Together

Reporting both preventive and problem-oriented services on the same date can often lead to inconsistent results with respect to reimbursement from payers. While some payers will reimburse the full allowable amount for both the problem-oriented E/M code and the preventive medicine services code, some will assess a co-pay for each service, and some will carve out the reimbursement for the problem-oriented E/M service from the payment for the preventive exam.  Some will simply deny the claim on the basis that they do not accept coding for both a preventive and problem-oriented service on the same date, regardless of the amount of the charge because, they say, you’re billing twice for the portions of the preventive and problem-oriented services that overlap.

Documentation is Key

The key to reimbursement for preventive medicine counseling and risk factor reduction services is documentation.  Documentation when submitting additional E/M services for reimbursement must meet the criteria to be considered a significant problem versus a trivial issue and documentation must meet the standards evaluation to justify billing for the additional service.  Without proper documentation as to the time spent counseling, the nature of the counseling and the problems addressed in performing significant E/M services the provider will not see significant reimbursement and will instead see denials of claims.