CMS and Obesity
You Can Now Receive Medicare Reimbursement for Nutrition Counseling
Print This Post
The Centers for Medicare and Medicaid Services (CMS) has issued a decision memorandum that will allow you to be reimbursed for providing Medicare beneficiaries with intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥30. The agency suggests that more than 30% of the Medicare population will likely qualify for the new benefit.
Intensive behavioral therapy for obesity consists of the following:
- Screening for obesity in adults using BMI measurement calculated by dividing weight in kilograms by the square of height in meters (expressed in kg/m2)
- Dietary (nutritional) assessment
- Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise
To be eligible for reimbursement, the counseling should follow the “Five-A’s” format:
- Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
- Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
- Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
- Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
- Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
Providing that a Medicare beneficiary is obese, competent, and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician, or other primary care practitioner, and in a primary care setting, CMS covers:
- One face-to-face visit every week for the first month
- One face-to-face visit every other week for months 2-6
- One face-to-face visit every month for months 7-12, if the beneficiary meets the 3 kg weight loss requirement as discussed below
At the six-month visit, you must reassess the patient’s obesity and document the amount of weight lost. To be eligible for additional face-to-face visits occurring once a month for an additional six months, patients must have lost at least 3 kg (6.6 lbs) over the course of the first six months of intensive therapy and should be documented in the record. For patients who do not achieve this minimum weight loss during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six-month period.
CMS defines a primary care setting as one where clinicians are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community. This definition does not include emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, or hospices.
Jill Shuman, MS, ELS
Published December 6, 2011
Source: Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Centers for Medicare & Medicaid Services Website. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=253. Published November 29, 2011. Accessed November 30, 2011.
what procedure code and diagnosis code shall we use to get re-imbursement?.
They haven’t written the codes yet even though reports are that coverage begins immediately.
Anyone thought of the unintended consequences of this new benefit?
15 million obese Medicare patients can see their primary care doctor for “free” up to 20 times in one year for face to face obesity counseling.
That’s potentially 300 million doctor visits which is 100 million more office visits then Medicare patients see their primary doctor now for all reasons. (there are nearly 50 million Medicare patients who see their primary care doctor an average four times a year)
Before CMS issued this ruling, they did no actual cost benefit analysis; no estimate of the total cost of the program or whether this new service can even be delivered. (Isn’t there a well known projected shortage of primary care doctors?)
I have not read a single news story or commentary that point out any of these small issues.
The goal in noble, no question. However, the Affordable Care Act gave CMS the power to do this which rivals anything Soviet era central planning ever tried to accomplish.
Meanwhile, if Congress can’t get its act together in the next two weeks, physicians are going to take a 27.4% cut in Medicare reimbursements on January 1st. Where’s Alice? I think I’m in a rabbit hole.
What are the qualifications necessary of the person giving the counselling? Does anyone know where that info is posted?
It must be delivered by a “primary care provider” in a “primary care setting.” Here’s the link to the memo with the most detail.http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253&
Intensive behavior therapy is based operant conditioning, which physicians are not trained in. Some psychologists, social workers and clinical counselors have the needed training. Intensive behavior therapy for obesity is only evidence-based psychological treatment.
Coding, reimbursement and conditions still are the big question. I am looking forward to finally getting paid from Medicare for my behavioral modification and weight management program.