Effective with dates of service on or after November 29, 2011, Medicare covers IBT for obesity,defined as a body mass index (BMI) of 30 kilograms per meter squared, for the prevention or early detection of illness or disability. IBT for obesity consists of the following:
- Screening for obesity in adults using measurement of BMI, which is calculated by dividing weight in kilograms by the square height in meters;
- Dietary (nutritional) assessment; and
- Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.
Medicare provides coverage of IBT for obesity (BMI ≥ 30 kilograms per meter squared) for Medicare beneficiaries:
- 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.
Each IBT for obesity must be consistent with the 5A’s approach adopted by the USPSTF. This approach includes:
1. Assess: Ask about or assess behavioral health risk(s) and factors affecting choice of behavior change goals or methods;
2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits;
3. Agree: Collaboratively select appropriate treatment goals and methods based on the beneficiary’s interest in and willingness to change the behavior;
4. Assist: Using behavior change techniques (self-help and/or counseling), aid the beneficiary in achieving agreed-upon goals by acquiring the skills, confidence, and social or environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate; and
5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance or support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
Frequency of coverage
Medicare covers a maximum of 22 IBT for obesity sessions in a 12-month period. Medicare beneficiaries who meet the previously mentioned criteria are eligible for:
- One face-to-face visit every week for the first month;
- One face-to-face visit every other week for months 2 – 6; and
- One face-to-face visit every month for months 7 – 12, if the beneficiary meets the 3 kg (6.6 pounds) weight loss requirement during the first 6 months.
At the 6-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 6 months, beneficiaries must have achieved a reduction in weight of at least 3 kg (6.6 pounds) over the course of the first 6 months of intensive therapy. This determination must be documented in the physician office records for applicable beneficiaries consistent with usual practice.
For beneficiaries who do not achieve a weight loss of at least 3 kg (6.6 pounds) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.
EXAMPLE: A beneficiary gets the first IBT for obesity session in January 2012 and gets all 22 sessions. The count starts February 2012. The beneficiary may get another first IBT for obesity session in January 2013.
Coinsurance or Copayment and Deductible
The beneficiary pays nothing (no coinsurance or copayment and no Medicare Part B deductible) for IBT for obesity. Financial responsibilities may apply for the beneficiary if the provider does not accept assignment.
Medical records must document all coverage requirements, including the determination of weight loss at the 6-month visit.
For more information on CPT, ICD, Speciality Types and POS codes, please visit “New Screening code G0447 for Intensive Behavioral Therapy (IBT) for Obesity”