How to get paid

Payment methods for providing weight management visits for patients vary by the role of the person providing the care and the patient’s primary and any secondary health insurance plans. Below we will include information on getting paid and billing for these types of professionals:

  • Medical provider (physician, nurse practitioner, physician assistant)
  • Nurse (RN or BSN)
  • Behavioral health provider
  • Registered dietitian (RD, RDN)

Coverage of these services vary significantly across insurance plans and, if there is any uncertainty about coverage of a service, it is recommended that you contact the patient’s health insurance plan(s) to confirm coverage of these services before billing the plan.

 

Medical Provider


Maximum reimbursement for weight management comes from using conventional E&M codes for weight-related comorbidities, not obesity itself, at the current time.  Therefore, we recommend using one or more weight-related comorbidity as the primary diagnosis(es) and obesity as a secondary diagnosis.  The weight management smart set includes a list of the most common weight-related comorbidities recognized by CMS for reimbursement through assistance with weight loss.  Remember, weight-related comorbidities range from metabolic to malignancy to mobility to mental health.  More than diabetes qualifies.  If a patient does not have any weight-related comorbidity, you can use an obesity E&M or Z code, but reimbursement will be lower.

Nurse visits between medical provider visits:


This is a registered nurse (RN) and not a medical assistant or LPN. 

For an established patient with a care plan for weight-related comorbidities 99211 is often billable for RN services performed in-person and may be performed via audio-video telemedicine visits if covered by the patient’s plan. There needs to be a clear link between the physician/APP’s initiated and ongoing plan of care and the weight check.

CPT code 99211 may be used to bill for a weight check when the following documentation is present in the nurse's note.

  • All vital signs should be recorded
  • The clinical reason for the check is clearly documented in the note.
  • A list of the patient’s current medications with his/her compliance level.
  • The physician's evaluation of the clinical information from the encounter and his or her management decisions.
  • Clear identity of the nurse(s) and his or her credentials.    

Caution: The patient who “drops in” to get a weight check because they are in the area would not qualify for the 99211 because the physician did not order the service and there are no clinical indications to warrant the 99211.

A phone-only interaction by the RN would not support a billable service.

For Medicare beneficiaries with obesity, who are 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

    1. One face-to-face visit every week for the first month;
    1. One face-to-face visit every other week for months 2-6;
    1. One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement as discussed below.

At the six-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg (6.6 lbs) over the course of the first six months of intensive therapy. This determination must be documented in the physician's office records for applicable beneficiaries consistent with usual practice. For beneficiaries who do not achieve a weight loss of at least 3kg (6.6 lbs) during the first six months of intensive therapy, a reassessment of both their readiness to change and their BMI level is appropriate after an additional six-month period.

2020-Obesity-Counseling-Reimbursement-Fact-Sheet-045443-191120.pdf (jnjmedtech.com)

Behavioral health provider (BHP):


To make engagement in behavioral weight management support for your clinic sustainable, it is good to ensure that billing practices support the work. Billing for BHPs in integrated primary care settings depends on a number of factors including your state’s guidelines, credentials, and type of visit. Psychotherapy codes (90791; 90832; 90834; 90837, etc.) require a mental health diagnosis. Patients who have a comorbid mental health diagnosis that is impacting their ability to successfully manage their weight might allow this type of billing. Absent a mental health diagnosis, there may still be patient behaviors or psychosocial concerns that are impacting a medical condition. Psychological Factors Affecting a Medical Condition (PFAMC; F54) is one such diagnosis that may be pertinent in situations in which patients’ behaviors are affecting their obesity.

Some private plans permit credentialed licensed clinical behavioral health providers to bill for weight management or nutrition services provided by a non-physician (S9452, S9470, S9449, S9452). The BHP can bill the following Health Behavior CPT Codes: 96156 (health behavior assessment or re-assessment), 96158 (health behavioral intervention, individual, F2F, initial 30 minutes) and 96165 (for each additional 15 minutes), listing separately in addition to code for primary CPT code. See https://www.apaservices.org/practice/reimbursement/health-codes/descriptors.pdf for more information.

Health and Behavior Codes are also available to bill for medical conditions as primary to the visit. Further information on billing for behavioral health can be found in the links:

 

Registered dietitian/nutritionist (RDN):


Dietitians’ services may be covered per CMS for patients with a confirmed diagnosis for type 1, 2, or gestational diabetes.  Most other visits with a registered dietitian will be self-pay.  

Here are some options for RDNs for billing:

  • RDNs can bill Medicare and Medicare Advantage plans for delivering Intensive behavioral therapy (IBT) for obesity as “incident-to” a primary care provider at the same rates of $27, on average, for G0447. However, providers using this model reported that the visit usually takes longer than 15 minutes. 
  • RDNs can bill directly for medical nutrition therapy (MNT), usually for a total of 3 hours in the first year and 2 hours in subsequent years. Medicare only pays for MNT if there is another condition, such as diabetes and chronic kidney disease. On average, Medicare pays $38 for the initial 15-minute visit (97802), $33 for each subsequent 15-minute visit, or $17 per beneficiary for 30-minute group sessions.
  • In addition, some private payers may permit "incident-to" billing for preventative medicine codes (99401-99404, 99411-99412). 
  • Some private plans may require a patient co-pay or co-insurance payment in these situations. 
  • Patients can self-pay. This usually doesn’t work, especially in areas with lower-income patients, as patients are not able to pay or do not perceive the value of having RDN counseling as something they should pay for.

To find a nutritional program in your area:

https://www.findhelp.org


Some additional information related to billing is available at: 
https://medschool.cuanschutz.edu/weightmanagementinprimarycare. The sections under the tab “Models” and “Hire a Professional” list some options for reimbursement for most health insurances.

 

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PATHWEIGH: Pragmatic weight management in primary care

CU Anschutz

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pathweigh@cuanschutz.edu

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