Medicare Intensive Behavioral Therapy for Obesity Progress Note (Individual)

Date of Service: [date]

Patient: [name, DOB, MRN]

Provider: [name, credentials]

Encounter Type: IBT Obesity – Individual (G0447)

Setting: [primary care site name]

IBT Benefit Period Tracking

• IBT start date (12-month anchor): [date]
• Visit number within benefit period: [Visit X of up to 22]
• Cadence phase: [Phase A: Weeks 1–4 weekly / Phase B: Months 2–6 biweekly / Phase C: Months 7–12 monthly if eligible]
• 6-month reassessment due today: [Yes / No]

Eligibility & Anthropometrics

• Weight today: [value and units]
• Height: [value and units]
• BMI: [numeric value] kg/m² (Confirm ≥30 for IBT eligibility; if BMI cannot be calculated, flag as not billable for IBT.)
• Weight change since baseline: [value with sign and reference date]
• Weight change since last visit: [value with sign]
• Patient alert and competent to participate: [Yes]

Interval History & Assessments

[Progress since last visit including: status of prior goals, barriers encountered, current eating patterns and dietary habits, current physical activity level and any limitations, relevant changes in sleep/stress/medications affecting weight]

(For first visit in benefit period, focus on baseline dietary and activity assessment only.)

Behavioral Counseling (5-A Framework)

Assess

• [Weight trend reviewed with patient]
• [Readiness and confidence level]
• [Behavioral factors: sleep, stress, mood, triggers]
• [Review of prior goals and barriers]

Advise

• [Personalized dietary recommendations]
• [Personalized physical activity recommendations]
• [Health benefit framing linking recommendations to outcomes]

Agree

• [Nutrition goal]
• [Physical activity goal]
• [Self-monitoring or behavioral goal]

(Collaboratively set 1–3 SMART goals.)

Assist

• [Practical support provided: skills training, problem-solving, planning]
• [Tools, handouts, or apps provided]
• [Referrals or care coordination if applicable]

Arrange

• [Follow-up date and interval per cadence phase]
• [Interim supports if planned]

6-Month Reassessment

(Include only when 6-month reassessment is due.)

• Baseline weight and date: [value, date]
• Today's weight and date: [value, date]
• Total weight change over 6 months: [value in kg and %]
• Meets ≥3 kg loss requirement: [Yes / No]
• Eligibility for months 7–12: [Eligible to continue monthly IBT / Not eligible]
• [If not eligible, document alternative plan]

Attestation & Signature

I confirm that 15 minutes of face-to-face intensive behavioral therapy for obesity (G0447) were furnished today, including BMI verification, dietary assessment, and behavioral counseling consistent with the 5-A framework.

Provider Signature: [name, credentials] | Date/Time: [timestamp]

(Coverage-critical elements required every visit: benefit period tracking, BMI, dietary assessment, and all 5-A content. Omit other content when not applicable rather than inserting N/A.)