Provider Notice issued 01/24/14

REVISED - 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.

Clinical Guidelines

Providers 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.

Body Mass Index Assessment Documentation in Claims

Annually, 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:

1. The date on which the BMI percentile was assessed

2. One of the following measurements:

• BMI percentile, or

• BMI percentile plotted on age-growth chart

3. If indicated, pertinent recommendation or plan of management consistent with the codes used.

Weight Management Visits: BMI >85th Percentile

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

Additional Notes on Payment Policies Related to Weight Management

1. Weight management visits cannot be billed on the same day as a Preventive Medicine visit.

2. 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