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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUPMC Health Plan Weight Management Coverage | Open…
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    CurrentUPMC Health PlanPolicy N/A

    Childhood Nutrition and Weight Management Services

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    Payment, billing, documentation, provider eligibility, coding, and service limits for Childhood Nutrition and Weight Management Services provided to eligible Pennsylvania Medical Assistance recipients under age 21.

    Policy Summary
    PayerUPMC Health Plan
    PolicyChildhood Nutrition and Weight Management Services
    Policy CodePolicy N/A
    Change TypeNew service coverage and billing guidance
    Effective DateNovember 1, 2007
    Next Review DateN/A
    Key ActionProviders must document the medical necessity of each Childhood Nutrition and Weight Management Service in the child's medical record.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Under 21Eligible recipient age
    30 minutesMinimum assessment duration
    3/365 daysInitial assessment limit
    4/365 daysReassessment limit
    24 units/365 days

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Counseling limit
    2-10Group counseling size

    Coverage and Payment Requirements

    General coverage requirements

    Payment is available for eligible Pennsylvania Medical Assistance recipients under age 21 who are overweight, obese, or experiencing weight management problems, when services are medically necessary and provided by enrolled eligible providers.

    Recipient and medical-necessity requirements

    • ALL of the following

      • Recipient is under 21 years of age
      • Recipient is overweight, obese, or experiencing weight management problems
    • Service is medically necessary

      Document the medical necessity of each service in the child's medical record in accordance with 55 Pa.Code § 1101.51.

    • Eligible enrolled provider or facility

      • Service is rendered by an enrolled physician, CRNP, registered nurse, nutritionist, outpatient hospital, independent medical surgical clinic, federally qualified health center, or rural health clinic, as applicable to the service

    Billing and service-limit requirements

    Coverage and payment are subject to service-specific billing rules, diagnosis coding, same-day billing provisions, and frequency limits.

    Billing and payment conditions

    • Initial assessments and reassessments are billed with the appropriate five-digit diagnosis code from 278.00 through 278.02 together with the applicable BMI V-code: V85.54, V85.53, or V85.52

    • Permitted same-day billing

      • A physical examination or complete EPSDT screen and an initial assessment or reassessment are rendered to the child on the same day
      • An office visit or clinic visit and a Childhood Nutrition and Weight Management Service are rendered on the same day, and the child is not being seen solely for a Childhood Nutrition and Weight Management Service
      • An initial assessment or reassessment and individual, group, or family weight management counseling are rendered to the child on the same day

    Procedure Codes and Service Limits

    Added procedure codes and informational modifierCPTCovered
    96151Health and behavior assessment, including reassessment, each 15 minutes, face-to-face with the patient; informational modifier TJ
    96153Health and behavior intervention, group, each 15 minutes, face-to-face; informational modifier TJ
    96154Health and behavior intervention, family, each 15 minutes, face-to-face with the patient present; informational modifier TJ
    Procedure codes with pricing and informational modifiersHCPCSCovered
    96150Health and behavior assessment, initial assessment, each 15 minutes, face-to-face; pricing modifier U3 and informational modifier TJ
    96152Health and behavior intervention, individual, each 15 minutes, face-to-face; pricing modifier U3 and informational modifier TJ
    S9470Nutritional counseling, dietitian visit; pricing modifier U3 and informational modifier TJ
    T1015Clinic visit defined for initial assessment, reassessment, individual intervention, group intervention, family intervention, or nutritional counseling, with service-specific modifiers
    Diagnosis and BMI codes for initial assessment and reassessmentmixedCovered
    278.00-278.02Required five-digit diagnosis code range for initial assessment and reassessment claims
    V85.54BMI greater than the 95th percentile and above; obesity
    V85.53BMI from the 85th to less than the 95th percentile; obesity
    V85.52BMI from the 5th to less than the 85th percentile; obesity
    Initial assessment frequency
    Maximum frequency3 initial assessments per child
    Measurement period365 consecutive-day period
    Service typeInitial assessment
    Reassessment frequency
    Maximum frequency4 reassessments per child
    Measurement period365 consecutive-day period
    Service type

    Provider Responsibilities

    Documentation Required

    Support medical necessity and coordinate care

    Ensure the child has had a recent EPSDT screening or physical examination, as appropriate, to help support medical necessity for the initial assessment, reassessment, and any additional Childhood Nutrition and Weight Management Services. Providers who conduct the initial assessment or reassessment and refer the child for other services should coordinate those services with the rendering provider.

    Documentation Required

    Document medical necessity

    Document the medical necessity for each Childhood Nutrition and Weight Management Service in the child's medical record in accordance with 55 Pa.Code § 1101.51.

    Prior Authorization

    Request additional services beyond limits

    Service Definitions

    Initial assessment
    PurposeDetermines the need for other Childhood Nutrition and Weight Management Services
    Typical evaluationDaily caloric intake, physical activity, meal and snack patterns, and readiness to change
    Measurements and planningWeight, height, BMI, BMI percentile, blood pressure, pulse, physical symptoms, and a coordinated nutrition and weight management plan
    Reassessment
    PurposeGauges the child's progress in weight management-related treatment
    Medical necessityDetermines whether services continue to be medically necessary and appropriate
    Policy Summary
    PayerUPMC Health Plan
    PolicyChildhood Nutrition and Weight Management Services
    Policy CodePolicy N/A
    Change TypeNew service coverage and billing guidance
    Effective DateNovember 1, 2007
    Next Review DateN/A
    Key ActionProviders must document the medical necessity of each Childhood Nutrition and Weight Management Service in the child's medical record.
    SourceLink
    On This Page
    Coverage and Payment RequirementsProcedure Codes and Service LimitsProvider ResponsibilitiesService Definitions

  1. Service limits

    • Initial assessment frequency does not exceed 3 assessments per child per 365 consecutive-day period
    • Reassessment frequency does not exceed 4 reassessments per child per 365 consecutive-day period
    • Each initial assessment and reassessment is at least 30 minutes
    • Combined individual, group, and family weight management counseling does not exceed 24 15-minute units of service or clinic visits per child per 365 consecutive-day period

  2. Additional services beyond limits

    • The applicable service limits are not exceeded
    • Additional services are medically necessary and approved through a Program Exception, also known as an 1150 Administrative Waiver, requested on an MA 97 Outpatient Services Authorization Request form with detailed justification and rationale
    3. Reassessment
    Counseling units
    Combined limit24 15-minute units or clinic visits per child
    Included servicesIndividual, group, and family weight management counseling
    Measurement period365 consecutive-day period
    Assessment duration
    Initial assessmentAt least 30 minutes per assessment
    ReassessmentAt least 30 minutes per reassessment
    Duration standardThe minimum applies to each assessment
    Group counseling size
    Minimum group size2 children
    Maximum group size10 children
    SettingGroup weight management counseling

    If an individual child requires additional Childhood Nutrition and Weight Management Services beyond the service limits, request a Program Exception, also known as an 1150 Administrative Waiver. Complete an Outpatient Services Authorization Request form (MA 97) and include detailed justification and rationale supporting the necessity of the additional services.

    Billing Rule

    Submit required codes and diagnosis information

    Use the procedure codes and code descriptions, provider types and specialties that may bill, modifiers, fees, and limits shown on the applicable chart. For initial assessments and reassessments, include the appropriate five-digit diagnosis code 278.00 through 278.02 together with the applicable BMI V-code on the claim form.

    • Use the 278.00–278.02 diagnosis range with the applicable BMI V-code for initial assessment and reassessment claims.
    • Applicable BMI V-codes include V85.54, V85.53, and V85.52.
    Documentation Required

    Meet nutritionist enrollment requirements

    To enroll as a provider of nutritional counseling, a nutritionist must have current Pennsylvania dietitian-nutritionist licensure from the Department of State and current certification from the Commission on Dietetic Registration (CDR). Nutritionists already enrolled in the Medical Assistance Program for nutritional consultation services under the AIDS Waiver Program may provide this component without submitting another enrollment application.

    Treatment adjustment
    Determines whether the frequency, amount, or duration of services should be adjusted
    Individual weight management counseling
    ParticipantsOne individual child
    FocusThe child's specific, personal, unique needs
    GoalsThe child's nutrition and weight management goals
    Group weight management counseling
    ParticipantsA group of at least 2 and no more than 10 children
    SettingGroup counseling setting
    ApproachInteraction among group members discussing difficulties surrounding weight management
    Family weight management counseling
    ParticipantsThe child and other members of the child's family
    FocusDevelopment of family weight management goals and behaviors
    Attendance requirementThe child must be present during the counseling session
    Nutritional counseling
    RecipientIndividual child
    FocusProper nutrition and eating behaviors to support weight management goals and maintain good health
    Covered topicsDietary interventions, food management, special nutrition needs, supplements, and the child's nutritional care plan