Payment System Thwarts Efforts to Treat Obesity : Many physicians try to get counseling reimbursed by coding for related comorbidities such as diabetes.


With the obesity epidemic growing, physicians are facing a payment system that hasn't caught up.

Although coverage varies by payer, most Medicare carriers do not pay for office visits coded only for obesity and the same is true for most private payers, physicians told this newspaper.

“The payment mechanism is certainly lagging behind,” said Sandra Hassink, M.D., a member of the American Academy of Pediatrics' national task force on obesity and director of the weight management program at the Alfred I. duPont Hospital for Children in Wilmington, Del.

As a result, many physicians find ways to get counseling paid for by coding for related comorbidities such as diabetes or heart disease, said Donna E. Sweet, M.D., chair of the board of regents of the American College of Physicians and professor of internal medicine at the University of Kansas in Wichita.

But that's far from a perfect solution, she said. If physicians could code for obesity as the primary diagnosis they could spend less time trying to work around the payment system, she said. And they could perform early interventions to keep obesity and overweight from leading to diabetes and heart disease, she said.

Payment for obesity counseling and interventions is part of a larger problem with the episode-driven payment approach, she said. “So much of this revolves around fixing our payment system,” Dr. Sweet said.

But there isn't complete agreement about whether third-party payment for obesity treatment would help patients, said G. Michael Steelman, M.D., a bariatric physician in Oklahoma City and president of the American Society of Bariatric Physicians. Many members of his group are split on this issue, he said.

One side argues that if insurers would pay for this care, patients would seek it out and stay in treatment. But others say that requiring patients to pay for these services out of pocket provides financial motivation to follow their physician's advice. “In obesity, there's a lot of work the patients needs to do when they leave the office,” he said.

Dr. Steelman said he favors a compromise position in which reimbursement is conditional on some measure of success. For example, payers could cover visits as long as the patient is losing weight or maintaining weight below a certain point, he said.

The bottom line, Dr. Steelman said, is that insurers will generally be unwilling to invest in obesity interventions until physicians can demonstrate that they are getting results.

In the meantime, physicians should learn how to code so they have the best chance of getting paid for their time, said Jamie Calabrese, M.D., a member of the American Academy of Pediatrics' national task force on obesity and medical director of the Children's Institute in Pittsburgh, Pa.

While most carriers won't pay for interventions associated only with obesity, most patients who are obese have other comorbidities. Dr. Calabrese recommends that physicians code the comorbid condition as the primary diagnosis and including obesity as the secondary diagnosis. With that as the starting point, there are multiple ways to code for weight management counseling, she said.

Physicians can use the basic evaluation and management CPT codes (99212–99215) or, if the patient was referred by another provider, the physician can use the consultation codes (99241–99245). When spending extra time with a patient, physicians should use the prolonged face-to-face codes (99354–99355). The prolonged time codes can be used when the physician goes beyond the usual time for that visit but that time doesn't need to be continuous, Dr. Calabrese said.

Typically if physicians code accurately, they will get paid fairly, Dr. Calabrese said. And there is some movement on this issue as some insurers begin to provide payment for the obesity code, she said. There's a potential for a partnership between physicians and payers, who can provide physicians and patients with the tools they need to deal with obesity, she said.

Highmark Inc. of Pittsburgh is doing just that. Starting in January 2006, the health plan will include coverage for obesity interventions as part of its preventive health benefits package. That means that it will begin paying physicians who code for obesity as the primary diagnosis.

This is expected to result in two extra visits a year when coding for obesity alone, said Donald Fischer, M.D., chief medical officer for Highmark Inc. And it will allow the health plan to collect more information on obesity, he said.

Next Article: