Obesity and Related Co-Morbidities Coding Fact Sheet for Primary Care Pediatricians

While coding for the care of children with obesity and related co-morbidities is relatively straightforward, ensuring that appropriate payment is received for such services is a more complicated matter. Many insurance carriers will deny claims submitted with "obesity" codes (eg, 278.00), essentially carving out obesity-related care from the scope of benefits. Therefore, coding for obesity services is fundamentally a two-tiered system, where the first tier requires that the provider submit claims using appropriate codes and the second tier involves the practice-level issues of denial management and contract negotiation.

Part I of this Coding Fact Sheet will provide you with a guide to coding for obesity-related health care services. Part II will present strategies for pediatric practices to handle carrier denials and contractual issues.

PART I: CODING

Procedure Codes

Current Procedural Terminology (CPT©) Codes

Body Fat Composition Testing

There is no separate CPT code for body fat composition testing. This service would be included in the examination component of the evaluation and management (E/M) code reported.

Healthcare Common Procedural Coding System (HCPCS) Level II Procedure and Supply Codes

CPT codes are also known as Healthcare Common Procedure Coding System (HCPCS) Level I codes. The Healthcare Common Procedure Coding System also contains Level II codes. Level II codes (commonly referred to as HCPCS ("hick-picks") codes) are national codes that are included as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard procedural transaction coding set along with CPT codes.

HCPCS Level II codes were developed to fill gaps in the CPT nomenclature. While they are reported in the same way as CPT codes, they consist of one alphabetic character (A-V) followed by four digits. In the past, insurance carriers did not uniformly recognize HCPCS Level II codes. However, with the implementation of HIPAA, carrier software systems must now be able to recognize all HCPCS Level I (CPT) and Level II codes.

Diagnosis Codes

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes

PART II: DENIAL MANAGEMENT AND CONTRACT NEGOTIATION

The current private carrier coverage environment for obesity services is mixed. Private carriers may have health plans that do not cover obesity related services under the medical plan and it may be carved out of the benefits package completely or part of a disease management program.

The key is to determine the level of coverage by the health plan for obesity evaluation and treatment. If the health plan denies an appropriately coded service for obesity:

**Determine the nature of the denial to determine the appropriate follow up.

**Review the carrier’s denial letter or explanation of benefits (EOB) for the reason for the denial. Most commonly provided reasons are due to bundling of services, or it is a carve out from the medical plan benefits or it is a non-covered service.

• Bundling Obesity evaluation and treatment services may be bundled with the Evaluation and Management (E/M) services by the carrier. The CPT codes listed in Part I represent separately identifiable services and should be reported as such. While there is no legal mandate requiring private carriers to adhere to CPT guidelines, it is considered a ‘good faith’ gesture for them to do so, given that the guidelines are the current standard within organized medicine. All inappropriate bundling of services should be appealed by the pediatric practice to the carrier.

• Carve-out Some carriers may carve out obesity related services from the provide network to a smaller specialty network or a disease management program. The pediatrician may consider contacting the carrier to determine the extent of the carve-out and to what degree coverage and payment is available for obesity related services. As a contractual issue between the health plan and pediatric practice, the pediatrician may discuss with the carrier to be part of the network or disease management program.

• Non-covered service Carriers may have different levels of health plan benefits and the family may be covered by a health plan with limited benefits coverage that do not provide any benefits coverage for obesity related services. In these situations, the family would be financially responsible for services provided to evaluate and treat obesity.

Strategies to enhance coverage:

In addressing issues with carriers, strategies include filing appeals and negotiating contractual provisions. A sample letter to send to carriers regarding bundling and carve-outs is included.

• Filing appeals Pediatric practices can follow these general guidelines when appealing claim denials or partially paid claims (excerpted from Appealing Claim Denials Can Improve the Bottom Line, AAP News, June 2004):

  1. Review all carrier explanation of benefits (EOB). Compare the billed amount and CPT codes with the EOB to determine the level of discounts, denials, inappropriate carrier re-coding or partial payments.

  2. Make sure the claim was prepared properly, that all information is correct and documentation supports the CPT codes. Once assured the denial was not due to an error on the practice’s part, proceed with the appeal.

  3. Send appeals in writing and to the right person — look up the contact person in the contract or call the carrier, explain the situation and what is coming so they can be on the lookout. If you are not satisfied with the response, contact the plan’s medical director.

  4. Send the appeal by certified mail to verify receipt by the health plan.

  5. List the member’s name, carrier identification number and claim number on all documentation.

  6. State your case in objective and factual terms. Identify the result you want and provide medical justification and CPT coding guidelines to support your case (keep in mind most claim processors do not have a medical or coding background, so be clear and specific). Sample appeal letters that can be used as templates are available on the Member Center of the AAP Web site (www.aap.org/moc) under the Private Sector Advocacy page.

  7. Suggest how denials can be avoided in the future, particularly if it is a recurring problem.

  8. Monitor for a response. If the carrier does not respond within the time frame specified in your initial appeal, follow up with a second letter.

  9. Create a spreadsheet to track appeals to each carrier so at contract renewal time, you can determine whether to continue to work with that carrier and identify items to modify in the contract.

  10. Each health plan should have a written statement explaining the procedures required for both first and second level appeals. If it is not excluded in the contract, and the practice has correctly coded and properly documented the services, continue to appeal. Should further action be required, contact the state department of insurance or depending on the state in which you practice, the state department of banking and insurance or state department of health. Most states have prompt pay laws. If a managed care organization violates the prompt pay law, the physician may be eligible for interest payments on the amount owed, depending on state law.

  11. If a claim is denied and the health plan informs that it is a non-covered service or is the plan member’s responsibility, bill the plan member and include a copy of the EOB and denial with the bill.

  12. Contact your AAP chapter to keep it aware of your issues. Some chapters have Pediatric Councils that meet regularly with health plan medical directors and Medicaid representatives to address coverage issues. Utilize the AAP Hassle Factor Form to report problems with carriers. (Some chapters have made the Hassle Factor Form available on their Web site, or it can be accessed on the Member Center).

• Negotiating contractual provisions In contacts with the health plans to discuss contractual issues, the key components are to:

  1. Address this issue with the person having authority to make decisions regarding payment. The carrier provider representative may not have the decision making authority in this type of matter.

  2. Focus the argument on how this is cost effective to the family and health plan as well as how it relates to quality care (provide documentation supporting your position).

  3. Frame your position on how it impacts the quality of care, cost effectiveness and patient satisfaction. Carriers are very conscious of quality issues, how a proposed change will affect overall expenses and efficiency, and their market share. The carrier’s current policy may not cover obesity related services and the carrier needs to be made aware of the impact to the patient, family, pediatrician and carrier.

  4. Consider notifying the family and employer since they may bring pressure onto the carrier and employer to expand health plan coverage.

AAP Activities

Some chapters have created pediatric councils that meet with carrier medical directors to discuss pediatric issues. AAP members may contact their chapter to report issues related to coverage for obesity with carriers. Members may also report carrier issues using the AAP Hassle Factor Form, available on the Member Center (www.aap.org/moc) under the "More Resources" link.

The AAP Private Sector Advocacy Advisory Committee is addressing coverage and payment issues for primary care and developmental and behavioral pediatricians including carve outs, health plan provider networks, coverage and compensation for evaluation and treatment and will be developing strategies and resources to help pediatric practices advocate for enhanced coverage and compensation for obesity. Refer to the AAP Pediatric Overweight and Obesity (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424) policy statement for recommendations for health care providers on the clinical assessment, prevention, and treatment of obesity.

For more information, contact the AAP Division of Health Care Finance and Quality Improvement at dhcfqi@aap.org.

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