Medicare Will Pay for Obesity Screening, Intervention, Says CMS

Financial Impact on FPs Still Unclear

December 07, 2011 04:55 pm Matt Brown

CMS' recent announcement( that obesity screening and counseling will be covered by Medicare could prove to be a boon for FPs, but it is too early to gauge the full impact of the agency's decision.

Cynthia Hughes, C.P.C., an AAFP coding and compliance specialist, said that the implications of the Nov. 29 announcement will not be known until CMS publishes claims processing rules and fee schedule values for the codes that will be used for these services, which now join Medicare's existing portfolio of preventive services available without cost-sharing according to the Patient Protection and Affordable Care Act.

"If the services are going to be bundled with other services on the same date, there is little value," Hughes told AAFP News Now. "If the codes are only bundled with preventive services, there may be value. With several new national coverage decisions for preventive counseling out there, it may be awhile before we see more detail."

Although the rule change means that, technically, Medicare beneficiaries should immediately be able to start receiving the services without having to make a copayment, in the absence of billing or coding guidelines, it may prove difficult for physicians to provide or even refer patients for a particular service, Hughes said.

Patrick Conway, M.D., M.Sc., CMS' chief medical officer and director of the agency’s Office of Clinical Standards and Quality, called the decision "an important step in aligning Medicare's portfolio of preventive services with evidence and addressing risk factors for disease."

story highlights

  • CMS has announced that obesity screening and intensive behavioral counseling now will be covered by Medicare.
  • According to an AAFP coding and compliance specialist, how these services are bundled will determine the financial impact for FPs.

The memo defined intensive behavioral therapy for obesity as consisting of

  • screening for obesity in adults using BMI measurement, with obesity defined as a BMI of 30 kg/m² or greater;
  • a dietary (nutritional) assessment; and
  • intensive behavioral counseling and behavioral therapy that promotes sustained weight loss through high-intensity interventions on diet and exercise.

Furthermore, said CMS, all such interventions should be consistent with the so-called 5-A framework highlighted by the U.S. Preventive Services Task Force, or USPSTF. This framework includes

  • asking about/assessing behavioral health risks and factors affecting choice of behavior change goals/methods;
  • giving clear, specific and personalized behavior change advice, including information about personal health harms and benefits;
  • collaboratively agreeing on appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior;
  • using behavior change techniques (e.g., self-help and/or counseling) to assist the patient to achieve agreed-upon goals by acquiring the skills, confidence and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate; and
  • arranging scheduled 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.

CMS indicated in the decision memo that it will cover one face-to-face visit every week for the first month in the primary care setting, followed by one face-to-face visit every other week for the next five months and one face-to-face visit per month for a second six-month period. To continue to receive counseling beyond the initial six months, however, the beneficiary must have met a weight-loss threshold of at least 3 kg (6.6 lbs.).