Medicare Pays for Obesity Counseling
Medical Economics Feature – May 2012
Tex Med. 2012;108(5):55-58.
By Ken Ortolon
Austin family physician John K. Frederick, MD, says his practice has been "deluged with obesity" and the illnesses that result from it, including diabetes, hypertension, obstructive sleep apnea, and heart disease.
"The inertia of poor diet and lack of exercise is overwhelming," Dr. Frederick wrote in an article published on the Texas Academy of Family Physicians website in March. "Repeated advice and encouragement often seem useless, and eventually it feels as if there is no point. Even the employees in our own clinic seem to be disproportionately affected with this condition."
That situation prompted Dr. Frederick's practice, Premier Family Physicians, to develop its own weight-loss program that includes counseling, a dietary instruction manual, periodic weigh-ins, and medications for those patients who want them.
Since it began in November 2011, the program has been successful, Dr. Frederick says. About 200 patients are enrolled; the first patients have seen their average weight drop 10 percent and their blood pressure decline about 5 percent. And, he says, Medicare and most private health plans pay for the service if physicians meet certain criteria.
Obesity counseling is one of about four dozen preventive care services the Affordable Care Act (ACA) requires Medicare and private insurers to cover without deductibles or copayments. Late last year, the Centers for Medicare & Medicaid Services (CMS) issued new regulations and a new billing code, G0447, for face-to-face behavioral counseling for obesity.
Texas Medical Association officials say it is uncertain how the private health plans will cover obesity counseling and other preventive services, or if they will offer the same coverage as Medicare. If they do, first-dollar payment for obesity counseling by Medicare and the private plans could significantly improve the health of patients suffering from obesity and its related illnesses and ensure that physicians are paid for providing a service that many patients need, they say.
Coverage for obesity counseling and other preventive services could disappear if the U.S. Supreme Court declares ACA unconstitutional. A decision in the case challenging that law is expected in June or July.
Paying for Prevention
Under ACA, Medicare and private health insurers must provide first-dollar coverage for obesity screening and other preventive care services included in the list of level A or B recommendations from the U.S. Preventive Services Task Force. That list includes about 45 services, such as alcohol misuse counseling, blood pressure screening in adults, breast cancer screening, and hearing loss screening in newborns.
Joseph Gave, director of TMA's Clinical Advocacy Department, says CMS has rolled our new guidelines and billing codes for these services since Congress passed ACA in 2010. The new guidelines and "G" code for obesity counseling took effect for all services provided on Nov. 29, 2011, or later.
A "G" code is a temporary code for billing for a new service until CMS develops a permanent CPT code.
Genevieve Davis, director of TMA's Payment Advocacy Department, says CMS also released guidelines and codes for intensive behavioral therapy for cardiovascular disease, screening and behavioral counseling for alcohol misuse, and screening for depression.
Mr. Gave says TMA is excited CMS addressed obesity counseling early in its ACA implementation process because obesity is a particularly acute problem in Texas.
Data compiled by the Texas Department of State Health Services indicate that 35 percent of adult Texans are overweight, while 32 percent are obese. The problem is even greater among minorities, with 41 percent of African-American adults and 39 percent of Hispanic adults classified as obese.
Health Affairs reported in 2009 that obesity was responsible for $147 billion in annual health costs for the nation, or about 9 percent of total health care spending. And, the Texas state comptroller estimates that obesity cost Texas businesses nearly $9.5 billion in lost productivity in 2009.
Under the new guidelines, Medicare pays for obesity counseling for beneficiaries with a body mass index (BMI) of at least 30 kilograms/meters2, who are competent and alert when they receive counseling, and who are counseled by a qualified primary care physician or other primary care practitioner, such as a nurse practitioner or physician assistant.
Patients who meet the criteria are eligible to have Medicare pay for one face-to-face visit every week for the first month and one face-to-face visit every other week for months two through six. They also can get one face-to-face visit in months seven through 12 if they meet the 6.6-pound minimum weight-loss requirements during the first six months.
According to a CMS MLN Matters newsletter, covered services include screening for obesity in adults using BMI measurement, dietary assessment, and intensive behavioral counseling to promote sustained weight loss through interventions on diet and exercise.
Intensive behavioral interventions include assessing behavioral health risks; giving clear, specific, and personalized advice for changing behavior; collaboratively selecting appropriate treatment goals and methods; helping patients achieve agreed-upon goals; and scheduling follow-up contacts for ongoing assistance and support.
For services that meet those criteria, physicians can bill the Healthcare Common Procedure Coding System code G0447 along with the appropriate codes for BMI of 30 or greater.
Medicare will pay claims for code G0447 only from family physicians, internists, obstetrician-gynecologists, pediatricians, nurse practitioners, certified clinical nurse specialists, and physician assistants.
A spokesperson for TrailBlazer Health Enterprises, the Medicare administrative contractor for Texas, says payment for code G0447 varies from $24.19 to $25.31 depending on geographic region.
For additional information on the new guidelines and the specific diagnostic codes, see the MLN Matters newsletter.
While ACA requires private health plans to cover obesity counseling and other preventive services at no cost to patients, TMA officials said it was unclear in late March exactly how all of the private plans would follow the Medicare guidelines.
"The ACA just says the service has to be covered with no patient copay," Ms. Davis said. "That doesn't mean the health plan has to pay for it. We are concerned that some health plans may bundle these other services into the actual preventive care visit."
Ms. Davis says TMA would seek clarification of how the private plans will handle obesity counseling during a series of meetings with the individual carriers that were slated to begin in late March.
But in an email to Texas Medicine, Dr. Frederick says most commercial plans cover visits involving obesity as long as the BMI is greater than 30, which is considered obese. He says they also cover counseling for those with a BMI of 27 or higher if the patient has a significant comorbidity, such as hypertensions or diabetes.
And, spokespersons for at least two of the plans – CIGNA and Blue Cross and Blue Shield of Texas – say their companies pay for the G0447 code. CIGNA spokesperson Mark Slitt says CIGNA follows the CMS guidelines for this billing code for its standard plans, but some employer-sponsored plans might have different limitations for some services, such as an annual limit of three visits for nutritional counseling.
It also was unclear how many physicians knew about and were billing for the new code as of late March. The TrailBlazer spokesperson said it had processed only about 90 Medicare claims for code G0447 as of late March.
Family physician Patrick Carter, MD, of Kelsey-Seybold Clinic in Houston, says his practice educates its physicians about the new benefit and how to document for obesity counseling. Norman Chenven, MD, founder and chief executive officer of Austin Regional Clinic, says his group has not focused much time or energy on this issue. It has had an established in-house obesity management program for more than 20 years that is self-pay and not intended for third-party reimbursement.
We tend to be very cautious around Medicare documentation issues because of our size and perceived vulnerability to the various headhunting entities that have been empowered to 'get' doctors for coding failures," said Dr. Chenven, whose multispecialty group includes about 300 physicians. "Therefore, we have a fairly rigorous approach to vetting the regulations, training our doctors and staff, and then self-auditing coding performance. We currently have a number of other initiatives that have taken precedence over obesity counseling."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Toolkit Helps Improve Patient Lifestyles, Health
TMA partnered with the American Medical Association to give physicians a toolkit to help patients improve their lifestyles and their health.
AMA Healthier Life StepsTM offers physicians and patients resources to make positive, coordinated lifestyle changes. It focuses on healthy eating, increasing physical activity, quitting smoking, and reducing risky drinking. It also includes a toolkit for physicians to improve their own lifestyles.
The concise, easy-to-read physician guide and toolkit offer physicians and their patients continuing medical education opportunities, patient questionnaires, action plans, progress calendars, and more.
The Healthier Life Steps program materials are free, courtesy of TMA and AMA. Physicians can earn up to 1 hour of AMA PRA Category 1 CME CreditTM for simply reading the physician guide.
For more information, you also may email TMA Outreach Coordinator or call (800) 888-1300, ext. 1470, or (512) 370-1470.
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