Intensive Behavioral Therapy for Obesity in a Hospital Owned Provider Based Physician Dept

Pub 100-03 Medicare National Coverage Determinations //Centers for Medicare &
Medicaid Services (CMS)//Transmittal 142//Date: February 03, 2012//
Change Request 7641

CMS's Decision Memo indicates this NEW -IBT Obesity service is to occur under a Practioner's "coordinated approach" including an outpatient hospital setting, their intent is for "appropriate staff" to participate in providing this new service, that it is covered when face to face by a particular practioner. (MD, PA, ARNP)


It is our practice that one of the Implications of Provider-Based Status in addition to the seven criteria, is the Medicare rules expressly prohibit Medicare coverage of the services of physician-employed auxiliary personnel furnished to hospital outpatients as services “incident to” physicians’ services. 42 C.F.R. § 410.26(b)(1), under the Medicare Physician Fee Schedule.

We are experiencing pressure from Dieticians who insist that their organization has indicted they can now be involved in this service.

The Question:

Can a Registered Dietician who has assigned benefits to a Hospital owned Provider Based Physician department Outpatient Setting, perform the facility portion of this G0477 service in a Hospital owned Provider Based Outpatient Setting, submitted under OPPS on a UB04 claim?

Auxiliary staff are under the Physicians/Non Phys (PA, ARNP) Direct supervision, (immediately available) who is overseeing the overall care. Its our understanding if a dietician performs, then NO professional component could be billed to the MPFS by a practioner, where there was no face to face 15 minute encounter by a practioner as stated in the NCD.

We are reluctant to approve this dietician argument, as presented in the scenario in RED above. A dietician performing the five "A"'s with the patient, does not seem to stand on its own or satisfy the requirement where a 15 minute was performed by a "face to face" practioner (MD, ARNP, PA), as required in the NCD.

Our interpretation is that a Dieticians documentation in the medical record would not support a a facility resource encounter, when solely performed by the dietician, even if cosigned by the Physician. And that this documentation would not be defendable, and would leave us at risk for audit purposes according to the NCD guidelines under Medicare.

Remember The billing rules and supervision are different for Hospital outpatient Provider Based physician owned depts.

Billing for free standing Physician offices vs Hospital Provider Based (owned) Outpatient Physician Dept are as folows .

Free Standing: Normally a free standing physician office bills the professional component and technical component if applicable on one 1500 claim to the Medicare Part B Carrier . The charge is paid under the MPFS Medicare Physician Fee Schedule, and place of service is always 11=office.


But a hospital owned provider based Outpatient physician Dept, must split their charge into two components

A facility fee component, (representing overhead, supplies and auxiliary personnel resources) billed on a UB04 to the Intermediary* & payable under OPPS Outpatient Prospective Payment System. [G0447-pays at the assigned APC #0432, for the National Unadjusted Payment of $35.66] (Note: *intermediary is now combined under the MAC umbrella)

The profee component is billed on a 1500 to the Medicare Part B MPFS fee schedule code of G0447 . And pays at the National Unadjusted payment for facility at $23.15. Place of service is always 22=Outpatient dept of hospital [This is billed on a 1500 claim form to the Carrier** Many times there is a modifier attached for the technical component TC or the professional component 26 if applicable on the ONE 1500 claim. It is our understanding G0477 does not have a TC/26 split. (Note Carrier is **now combined under the MAC umbrella)]

Thx Support needed