In July 2024, The American Journal of Lifestyle Medicine published an article entitled “Health and Wellness Coaching Services: Making the Case for Reimbursement.” Our very own, Wellcoaches Founder and CEO, Margaret Moore was the senior author. The Purpose of this article was to describe the path to reimbursement for Health and Well-being Coaching (HWC) forged by collaborators over the last five years. Led by the National Board for Health and Wellness Coaching (NBHWC) this group included the Veterans Health Administration (VHA) and more than 70 other concerned and involved organizations. This collaborative targeted and petitioned the American Medical Association’s Current Procedural Terminology (CPT) Panel and the Centers for Medicare and Medicaid Services (CMS). Ultimately, these oversight bodies determine the fate of reimbursement for health services.
In more detail, the first few paragraphs of the article describe our societal epidemic of lifestyle diseases and the need for an effective treatment promoting healthy behaviors. HWC is described as a patient-centered approach emphasizing behavior change while focusing on areas such as physical activity, nutrition, stress reduction, and sleep. The case is made for HWC as a credentialed, rapidly growing, and effective intervention to guide clients toward better health by preventing and managing lifestyle diseases.
HWC is said to align as part of a healthcare team. Physicians will refer patients to HWC services for personalized planning to support them in engaging their health care goals. Diverse healthcare and clinical models, where HWC is effectively integrated into patient care, includes sites such as VHA, Mayo Clinic, Massachusetts General Hospital, and University of California, San Diego.
The case for HWC reimbursement is made by providing four critical reasons:
Improving care quality
Supporting other healthcare professionals to reduce loads and potential for burnout
Empower patients in a cost-effective, socially and culturally sensitive manner
Directly support partners and stakeholders who are crucial to healthcare delivery
The Path to Reimbursement
In 2019, the VHA recognized the need for coding and tracking coaching services that was not possible with then-existing CPT codes. The VHA, with support from NBHWC, applied for and was successful in having approved Category III CPT codes for HWC. These codes are in effect until 2029 and they allow the VHA to continue using and evaluating HWC as an integral part of caring for the complex health needs of Veterans.
While Category III codes work well for the VHA, they are generally not reimbursed by public and private payers. Accordingly, the collaborative led by the NBHWC, sought to further petition the AMA and CMS for Category I CPT billing codes. This request required further documentation establishing the effectiveness and maturity of HWC as a viable healthcare profession.
This information included:
Evidence of HWC as effective for managing chronic disease – randomized and controlled (RCT) studies affirming HWC being used to effectively prevent and manage diabetes, hypertension, heart disease, obesity, stroke, chronic pain, and cancer in a variety of healthcare setting with a diversity of coaches.
Evidence for an effective dose of coaching – research review information to establish guidelines for HWC session duration, frequency, program length, and total dose. The CPT codes adopted these guidelines providing for a 60-minute introductory session and follow-up sessions of 30 minutes with up to 15 coaching sessions over 7-9 months. About 60% of the studies cited to establish this dosing framework were delivered remotely – aka – via telehealth.
Establishing coaches as qualified health professionals –evidence that NBHWC, with the National Board of Medical Examiners (NBME), established a credible national HWC certification based on approved national education and training standards. This process has resulted in over 10,000 certified coaches from a diversity of licensed and non-licensed practitioners.
Providing HWC Utilization data in the US - information from 72 organizations on use of coaching services. Since 2015 over 4 million coaching sessions were recorded. The VHA alone accounted for nearly 150,000 reported sessions delivered by certified coaches.
As a result of these more recent efforts for establishing CPT codes, the CMS announced in November 2023 that HWC were included on the 2024 Medicare Telehealth Services List. This action was taken on a temporary basis – now through 2027 - with the expectation that positive clinical outcomes will be documented using these new coaching CPT codes before permanent approval would be considered. CMS expects verifiable, peer-reviewed evidence to be provided to support the movement of HWC services to a permanent reimbursement code.
There are several pathways to use the temporary CPT codes for reimbursement of HWC services. Medical practices can directly bill patients or use monthly value-based care allowances to finance coaching services. Medical practices can bill Medicare for eligible beneficiaries who are using HWC services under physician supervision. Medical practices may also use the CPT codes to engage in negotiations for billing other third-party payers (e.g., Medicare Advantage plans or private insurance). Finally, Health Savings and Flexible Spending Accounts may reimburse HWC services when prescribed by a physician as medically necessary.
The Future for HWC
Going forward the HWC profession must ensure standardized HWC training and credentialing. Furthermore, clinical and financial outcomes for HWC must be tracked using standardized outcomes and the new temporary CPT codes. There also needs to be a substantial amount of work reported in underrepresented populations. The HWC field must also continue to document and identify important factors that contribute to positive outcomes such as consideration of patient readiness, coach experience, and technological advances. Recognizing and implementing these positive factors can help make a stronger case for HWC reimbursement to insurance providers. Finally, the HWC field must provide published clinical effectiveness evidence for HWC using the established, but temporary, telehealth services CPT codes.
The paper concludes by describing the tremendous development of the HWC profession over the last decade. Approval of CPT codes for HWC is evidence of this development! The future requires extensive use of these codes and documentation of such. These efforts will encourage development of the profession and reinforce the value of HWC by optimizing patient-centered resource use and coordinated care. This blog does not do justice to the detail provided in the full-length paper. To capture and appreciate these details, the reader is directed to the complete article.
REFERENCES
Abu Dabrh AM, Reddy K, Beech BM, Moore M. Health & Wellness Coaching Services: Making the Case for Reimbursement. American Journal of Lifestyle Medicine. 2024;0(0). doi:10.1177/15598276241266784