The growing obesity epidemic: What to do about outpatient obesity denials?

Nov. 21, 2018 / By Camille Ruiz, RHIA

As I look forward to pulling the turkey out of the oven tomorrow and placing it on the table between the gravy and the green bean casserole, I’m reminded of what I call “The Fourth Quarter 15.” Thanksgiving is the start of the holidays and many of us are likely to indulge or over indulge in seasonal feasts and desserts, so we put on pounds in the last quarter of the year.  It can be difficult to monitor our food intake even when we know it’s important.

This issue is the subject of a public health class called “The Principles of Obesity Economics,” taught by Kevin Frick, PhD, professor and Vice Dean for Education at the Johns Hopkins Carey Business School. The term “Obesity Economics” describes the incentives and constraints on human behavior when it comes to overeating, such as food prices and time (incentives) as well as budget and personal preferences (constraints). For example, it is cheaper and less time consuming to reheat a frozen meal or purchase fast food. Think of the planning, cost and time it takes to buy and preparre an organic, free-range chicken with fresh, organic vegetables. Relying on convenience food, however, will have an impact on your health and will eventually be costlier if your obesity increases along with the healthcare expenditures involved in treating it.    

The statistics: Based on 2015-2016 data from the National Center for Health Statistics (NCHS), the Centers for Disease Control and Prevention (CDC) reports that over 93 million U.S. adults are obese. There are both physical and emotional conditions related to obesity such as heart disease, diabetes, certain types of cancer and depression. In 2008, U.S. medical costs for treating obesity and obesity-related conditions in just adults were $147 billion. This doesn’t account for the medical cost of treating children and adolescents with obesity.

These statistics hit me in my revenue cycle core, especially after I read a Part B News article referencing a 29 percent denial rate for obesity counseling. This equates to roughly $5.5 million in lost revenue based on the Medicare claims data submitted. Capturing BMI codes is not a new concept. I decided to research further to find out why the denial rate continues to hold steady for obesity counseling claims. First, here are the G0447 CMS claims requirements:

  • Medicare patients with a BMI ≥ 30 are eligible for counseling
  • Counseling must be provided by a qualified primary care physician or other primary care practitioner. This includes:
    • Family Practice
    • General Practice
    • Internal Medicine
    • Obstetrics/Gynecology
    • Pediatric Medicine
    • Geriatric Medicine
    • Nurse Practitioner
    • Certified Clinical Nurse Specialist
    • Physician Assistant
  • Place of Service
    • Physician’s Office
    • State or local public health clinic
    • Outpatient Hospital
    • Free-Standing Clinic
  • Primary diagnosis must be from Z68.30 (BMI 30.0-30.9, adult) to Z68.45 (BMI 70 or greater, adult) with any associated obesity conditions such as diabetes, HTN or ASCVD being assigned as secondary diagnoses (SDx).

Z68.30 – Body mass index 30.0-30.9, adult
Z68.31 – Body mass index 31.0-31.9, adult
Z68.32 – Body mass index 32.0-32.9, adult
Z68.33 – Body mass index 33.0-33.9, adult
Z68.34 – Body mass index 34.0-34.9, adult
Z68.35 – Body mass index 35.0-35.9, adult
Z68.36 – Body mass index 36.0-36.9, adult
Z68.37 – Body mass index 37.0-37.9, adult
Z68.38 – Body mass index 38.0-38.9, adult
Z68.39 – Body mass index 39.0-39.9, adult
Z68.41 – Body mass index 40.0-44.9, adult
Z68.42 – Body mass index 45.0-49.9, adult
Z68.43 – Body mass index 50.0-59.9, adult
Z68.44 – Body mass index 60.0-69.9, adult
Z68.45 – Body mass index 70 or greater, adult

  • Primary service must be HCPCS G0447

If performed with another visit on the same date of service, G0447 will be denied. 

Modifier 25 may be assigned to the Initial Preventative Physical Examination (IPPE), Annual Wellness Visit (AWV) or Federally Qualified Health Center (FQHC) visit claims.

  • The visit frequency allowed:

One face-to-face visit every week for the first month;
One face-to-face visit every other week for months 2-6; and
One face-to-face visit every month for months 7-12, if the patient meets the weight loss requirement during the first 6 months.

A reassessment at the six-month visit must be performed to determine the total weight lost. The patient is eligible for additional visits If they lose at least 6.6lbs to meet the weight loss requirement. Patients who do lose the 6.6lbs required during the first six months of therapy should be reassessed and their BMI remeasured before continuing an additional six months.

The 5 “A” Approach Counseling Requirements (MLN Matters, Number MM7641 Revised):

Assess: Ask about or assess behavioral health risks and factors affecting choice of behavior change goals/methods.

Advise: Give clear, specific and personalized behavior change advice, including information about personal health harms and benefits.

Agree: Collaboratively select appropriate treatment goals and methods based on patient’s interest in and willingness to change behavior.

Assist: Using behavior change techniques (self-help and/or counseling), aid patient in achieving agreed upon goals by acquiring skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust treatment plan as needed, including referral to more intensive or specialized treatment.

The provider list omitted both cardiology and endocrinology physicians. This seems odd to me given the high prevalence of cardiovascular disease and diabetes related to obesity. The other oddity is the sequencing of the Z68* BMI code as primary. Most coders and CDI specialists have probably attended education sessions on FY 2019 Official Guidelines for Coding and Reporting Chapter 21 of the Official Guidelines for Coding and Reporting covering BMI codes. Assigning the ICD-10 > 40 BMI codes when documented is a SDx that potentially impacts Severity of Illness (SOI) and Risk of Mortality (ROM) levels, a Hierarchical Condition Category (HCC) and a potential complication or comorbidity (CC). I would have to make an extra effort to sequence if I were coding these accounts. I’m accustomed to BMI codes being SDx. After careful consideration, I believe this is the main issue causing denials. Although this blog will not reduce your waistline, I hope it helps in taking action to reduce your outpatient denials. Keep coding!

Camille Ruiz is an outpatient CDI consultant at 3M Health Information Systems.


CMS IOM, Publication 100-04, Chapter 18, Section 200 

CMS CD 210.12