Chapter 20: Obesity Treatment


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2013

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Table of contents

Definitions

Payment policy:
Obesity treatment

More info:
Related topics



Definitions

Body Mass Index (BMI):

BMI is a number calculated from a person’s weight and height and is used as an indicator of body fatness (the higher the number, the more body fat).

Link: A BMI calculator is available on the National Institute of Health website, at: www.nhlbisupport.com/bmi/.

Severe obesity:

For the purposes of providing obesity treatment services, L&I defines severe obesity as a BMI of 35 or greater. (See definition of BMI, above.)

 


Payment policy: Obesity treatment  

Prior authorization

Parameters for coverage

All obesity treatment services require prior authorization.

Obesity doesn’t meet the definition of an industrial injury or occupational disease. Temporary treatment may be allowed when the unrelated obesity condition hinders recovery from an accepted condition.

To be eligible for obesity treatment services, the worker must be severely obese (have a BMI of 35 or greater).

Note: See definitions of BMI and severe obesity in “Definitions” at the beginning of this chapter.

Requesting a weight reduction program

The attending provider should contact the insurer to request a weight reduction program if the worker meets all of the following criteria:

  • Is severely obese, and
  • Obesity is the primary condition retarding recovery from the accepted condition, and
  • The weight reduction is necessary to undergo required surgery, participate in physical rehabilitation, or return to work.

The attending provider who believes that the worker may qualify for obesity treatment:

  • Must advise the insurer of the worker’s weight and level of function prior to the injury and how it has changed, and
  • Must submit medical justification for obesity treatment, including tests, consultations, or diagnostic studies that support the request, and
  • May request a consultation with a certified dietitian (CD) to determine if an obesity treatment program is appropriate for the worker.

Required: Treatment plan

Prior to receiving authorization for an obesity treatment program, the attending provider and worker are required to develop a treatment plan, which will include:

  • The amount of weight the worker must lose to undergo surgery, and
  • Estimated length of time needed for the worker to lose the weight, and
  • A diet and exercise plan, including a weight loss goal, approved by the attending provider as safe for the worker, and
  • Specific program or other weight loss method requested, and
  • Attending provider’s plan for monitoring weight loss, and
  • Documented weekly weigh-ins, and
  • Group support facilitated by trained staff, and
  • Counseling and education provided by trained staff, and
  • For State Fund claims, sign the Claim Manager generated authorization letter, which serves as a memorandum of understanding between the insurer, the worker, and the attending provider.

Note: The treatment plan won’t include requirements to buy supplements or special foods.

Authorization or not?

The insurer authorizes obesity treatment for up to 90 days at a time as long as the worker does all of the following to ensure continued authorization of the obesity treatment plan.

  • Loses an average of at least one to two pounds a week, and
  • Regularly attends weekly treatment sessions (meetings and weigh-ins), and
  • Cooperates with the approved obesity treatment plan, and
  • Is evaluated by the attending provider at least every 30 days, and
  • Pays the joining fee and weekly membership fees up front and is reimbursed by the insurer using the codes listed below, under Services that can be billed, and
  • Sends the insurer a copy of the weekly weigh-in sheet signed by the program coordinator every week.

The insurer will no longer authorize obesity treatment when any one of the following occurs:

  • The worker reaches the weight loss goal identified in the obesity treatment plan (see “Note,” below), or
  • Obesity no longer interferes with recovery from the accepted condition (see “Link,” below), or
  • The worker isn’t losing weight an average of at least one to two pounds each week, or
  • The worker isn’t cooperating with the approved obesity treatment plan.

Note: If the worker chooses to continue the weight loss program for general health, it will be at his or her own expense.

Link: To see more information about why it is prohibited to treat an unrelated condition once it no longer retards recovery from the accepted condition, see WAC 296-20-055.

Attending provider’s responsibilities

Upon approval of the obesity treatment plan, the attending provider’s role is to:

  • Examine the worker every 30 days to monitor and document weight loss, and
  • Notify the insurer when:
    • The worker reaches the weight loss goal, or
    • Obesity no longer interferes with recovery from accepted condition, or
    • The worker is no longer losing the weight needed to meet the weight loss goal in the treatment plan.

Who must perform these services to qualify for payment

Nutrition counseling

Only CDs will be paid for nutrition counseling services.

Note: Providers practicing in a state other than Washington that are similarly certified or licensed may apply to be considered for payment.

Services that can be billed

Nutrition counseling

CDs may bill for authorized services using these CPT® billing codes:

  • 97802 at initial visit, with a maximum of four units; the maximum fee per unit is $56.45, or
  • 97803 with a maximum of two units per visit and a maximum of three visits; the maximum fee per unit is $49.25.

Note: 1 unit of either CPT® 97802 or 97803 equals 15 minutes.

Expenses for weight loss program

The worker will be reimbursed for the obesity treatment program when billing using the following local codes:

  • 0440A (Weight loss program, joining fee, worker reimbursement), which has a fee limit of $157.26, and
  • 0441A (Weight loss program, weekly fee, worker reimbursement), which has a weekly fee limit of $31.46.

Services that aren’t covered

The insurer doesn’t pay the obesity treatment provider directly.

The insurer doesn’t pay for:

  • Surgical treatments of obesity (for example, gastric stapling, or jaw wiring),
  • Drugs or medications used primarily to assist in weight loss,
  • Special foods (including liquid diets),
  • Supplements or vitamins,
  • Educational material (such as food content guides and cookbooks),
  • Food scales or bath scales, or
  • Exercise programs or exercise equipment.

If you’re looking for more information about… Then go here:
Administrative rules for treating conditions unrelated to the accepted condition Washington Administrative Code (WAC) 296-20-055:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-055
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/
Billing instructions and forms Chapter 2:
Information for All Providers
Fee schedules for all healthcare facility services (including obesity treatment services) L&I’s website:
http://feeschedules.Lni.wa.gov
How to calculate BMI National Institute of Health’s website:
www.nhlbisupport.com/bmi/

Need more help? Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2012 American Medical Association

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