Think Weight Loss Is a Struggle? Try Documenting, Coding and Billing for It

Weight loss is not easy, as the more than 70 percent of Americans who are either overweight or obese can attest to. Providing obesity management services – and effectively documenting, coding, and billing for this work – is also challenging, as healthcare provider organizations can also confirm. While new weight loss treatments, primarily popular Glucagon-like peptide-1 (GLP-1) drugs, hold the potential to make weight loss a bit easier, they are simultaneously introducing even more complications into an already complex administrative process.  

To start, many primary care providers struggle with the administrative requirements associated with obesity management in general because it is just one of a seemingly unending myriad of services that they typically provide.

“Billing practices that primary care doctors have to go through are what I would loosely call Byzantine,” says Carl Knopke, MD, FMOA, FAAFP, a family practitioner and obesity medicine specialist who serves as the medical director of Inland Empire Weight Loss, Riverside, CA. “When you practice in a specific area, you're a neurosurgeon or a cardiologist, you're familiar with all the different ways that you can document, code, and charge for your services. When you are in either internal medicine or family medicine, you have a wider scope. You're kind of expected to do it all, but never really shown the way to document, code, and bill for your services.”

For instance, when providing obesity management services, physicians, coders, and billers need to be aware of CPT codes 99401, 99402, and 99403, which cover behavioral change therapy.

“Providers need to use the five As model, whenever they are addressing behavioral change: assess, advise, agree, assist, and arrange,” Knopke says.  

This therapeutic intervention is even more important when working with GLP-1 drugs. While some patients might erroneously think that weight loss drugs can act as a magic bullet of sorts, Knopke contends that GLP-1 therapies don’t work in isolation, but hinge on patients developing good habits to succeed. For example, patients need to eat more protein and participate in a strength training program to counteract some of the muscle loss associated with the GLP-1 drugs.

“I'm not going to prescribe these drugs to anybody who's not receiving behavioral therapy because otherwise I feel like I'm doing wrong because I'm restricting how well this person can do,” he says.  

Unfortunately, many provider organizations typically don’t offer (or bill for) behavioral change consultations because they are not aware of, nor skilled at providing, these services, Knopke says.      

“I work with the Obesity Medicine Association and we do a lot of educational efforts and … behavioral therapy is a brand-new concept to the cadre of physicians that we're teaching, but it is really not new, it's just that it's not taught in medical school and residency,” Knopke says.

Assessing Accuracy

In addition to being aware of potential services and associated codes, coders should work with physicians to make sure the clinical documentation and resulting codes are accurate and complete. This is especially important when working with GLP-1 drugs, where the patient’s status needs to be accurately captured.

“Anytime you have a new service, new procedure, new drug, you definitely want to pay attention to ensure you are capturing accurate data,” says Leonta Williams, MBA, RHIA, CPC, CPCO, CRC, CEMC, CHONC, CCS, CCDS, director of education for the American Academy of Professional Coders. “However, the physician might not be providing the documentation to  properly classify the patient's weight status, whether it's ‘obesity’ versus ‘morbid obesity’ versus ‘overweight’. Sometimes they use the documentation interchangeably.”

As such, if a provider says a patient is morbidly obese in the clinical documentation, coders should check to see if the patient qualifies as such, and actually has a body mass index over 40 per the clinical definition.

Coders also need to be aware of billing requirements. Some payers, for instance, only reimburse for GLP-1 drugs if the patient has a co-morbidity or receives other services such as nutritional counseling first, Williams says.

An understanding of such requirements becomes even more crucial with GLP-1 drugs, which have become so popular that many patients are requesting them, even when they don’t meet prescribing criteria and payer requirements.

“With a lot of these drugs, the intent is really to treat a chronic condition like diabetes, hypertension, or heart failure, and then the weight loss is secondary,” Williams says. “So, the coder needs to look for: Are these chronic conditions? Does the patient have a chronic condition or comorbidity that leads to the need for weight loss? And some payers want to see that your primary diagnoses is diabetes followed by that code for morbid obesity. It’s very risky business to try to manipulate the documentation in a manner that supports the payer’s requirements just to meet patient demand for the drugs.”

Collaborating with Clinicians

Indeed, because coders rely on documentation from clinicians to produce codes they “cannot adjust or make inferences of a condition that is not documented,” says Robin Tripp, MAS, RHIA, CCS-P, CPC, CRC, director of education, revenue cycle, and coding for AHIMA. “However, if coders have questions, they can complete a compliant clinical documentation query and the clinician can answer that query to provide clarity.”

Coders can also play a pivotal role by educating clinicians on payer-specific criteria. For instance, if various insurers require specific diagnostic criteria for weight loss treatments to qualify for coverage, coders are well-positioned to inform and guide clinical staff about these stipulations. This not only assists in maintaining billing compliance, but can also enhance the accuracy of clinical documentation.

“There's always an opportunity for coders to provide education in the sense of working in a collaborative relationship with clinicians. But coders are not educating clinicians on how to diagnose,” Tripp concludes. “Coders don't practice medicine. They also cannot tell clinicians that if a patient is not diabetic, for example, to put in the documentation that they're diabetic so that they can code diabetes in order to get a medication approved – no, absolutely not. But they can educate them on how to document with clarity, consistency, and completeness.”

John McCormack is a Riverside, IL-based freelance writer covering healthcare information technology, policy, and clinical care issues.