The Good and Bad of CPT Codes for Health Coaching

The medical establishment is starting to develop CPT Codes or “Current Procedural Terminology” more simply, procedure codes, for the purpose of billing insurance companies for health coaching services.  Functional Diagnostic Nutrition® stands for anything that expands the health coaching profession so, in that sense, maybe it’s not a bad idea.  

But Independent Health Coaches shouldn’t get their hopes up or give this too much consideration yet.  These things can take a while to develop and, more importantly, there are serious drawbacks to operating a business that depends on health insurance reimbursements.  

Compared to providing health services within a cash practice model, adding new procedure codes into the insurance model won’t advance the health coaching cause and may even work against health coaches.  In fact, one could argue that CPT III codes for health coaching are worthless in their current form.  

The Bureaucracy

Many CPT III codes end up dying on the vine and never become Class I (payment eligible) codes.  In order for a CPT III code to become a CPT Code and get on the fee schedule, there must be a critical mass of physicians adding the code to their practice so they show that (a) time is being spent performing these services and (b) there is clear evidence of a benefit in the services being performed.

In general, for part (a) to happen, health coaching visits have to be pushed at the medical society level to ensure enough physicians are adding the procedural code to warrant a review of the evidence and turn it into a Class I CPT code.  Given this code is being pushed by non-physician organizations, it’s questionable whether they’ll meet the criteria unless they really drive physicians to add the code to their billing administration.  

Meeting part (b) requirements may be even trickier.  

Generally, some sort of clinical evidence such as a randomized clinical trial associated with the service, showing better outcomes, must be presented. That makes part (b) criteria pretty challenging because someone needs to pay for and perform a clinical trial.  The only ongoing “health coaching” trial we found on clinicaltrials.gov  is being conducted to determine whether or not health coaches can influence patients to stay on their IBD medication.  That’s not something a group of professional, Independent Health Coaches have any interest in.  The need to meet both of these criteria is why many Class III codes never become Class I codes.  

The Establishment

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It’s exciting to see professional health coaching finally being recognized by the medical establishment.  However, this is an entirely patient-driven (market-driven) phenomena.  In general, the medical profession is a market-following body and is just waking up to the popularity and successes being achieved through Independent Health Coaching and similar outside services.  Those successes have been growing for at least a few decades and so, it should be recognized, its Independent Health Coaches who established the market and earned the recognition. 

Awareness of improved patient outcomes due to health coaching services provided from outside the medical establishment is coming to society’s attention through their patients, spouses, kids, parents and community members who are achieving health goals (not just managing symptoms and disease) by independently hiring health coaches, personal trainers, nutritionists, and allied professionals who are not embedded within that establishment.  

One would have to be blind to miss the trend towards and viability of non-medical health coaching services provided to consumers and – that it occurs almost entirely through out-of-pocket transactions.  The outcomes are hard to ignore and it’s only natural for the medical community to follow the trend and provide a similar service, but, is adding new CPT Codes the best solution?  Maybe for them, but not for Independent Health Coaches.

Will adding a couple CPT Codes for health coaching services in a doctor’s office provide patients with the same high quality and effective level of health-producing services they receive in a competitive, free-market system – and will they achieve the same results?  

Or will (now former) health coaching clients end up with some kind of watered-down, symptom-based, less results-oriented version of Independent Health Coaching services provided under a medical paradigm, not to mention burdensome insurance regulations and bureaucracy?

Former clients are being referenced because people will be less likely to hire an Independent Health Coach if they think they are getting the same services at their doctor’s office for “free.”  

Apples to Oranges

Health coaches have been filling the “needs gap” between medical treatment and real health-building for decades now.  So, it’s only to be expected that medical offices will bring on health coaching services.  But this CPT thing likely isn’t going anywhere but downhill if you’re an Independent Health Coach.

One concern is whether health coaching will just become another arm of the current Western Medicine system. Coaches could be used mostly as a compliance tool to preserve the same old routine of treating symptoms and managing disease.  There may be some health coaches who see value in working under a doctor and doing some good that way.  But one can also see how this could diminish the real value of health coaching and kill the entrepreneurial spirit and creativity that developed and expanded the field in the first place.

Professional health coaching means it is not a hobby for those practicing it.  It’s a business and its subject to the same influences that dictate the success of any business.  Supply and demand come to mind as does quality, delivery, customer service and in this case, results!  

The leadership provided by Independent Health Coaches who strive to educate clients about personal responsibility and the natural consequences of their own actions relating to health outcomes goes far beyond services currently provided in most doctor’s offices.  FDN has established health coaching as a legitimate profession since long before anyone ever heard the term.  Be assured, the earning potential for a professional health coach far exceeds whatever meagre reimbursement may finally be approved by the insurance industry as payment for a health coaching visit in a doctor’s office.

The Abyss

Many licensed physicians complain about pitiful reimbursement rates and some are struggling to see enough patients each week to pay the enormous overhead, student loans, malpractice insurance, medical equipment leases, and other expenses they incur, let alone take home a paycheck. According to Forbes, the average Chiropractor is $150,000 in debt by the time they graduate.   In the US, the average salary is about $85,000 per year and in some states, like Wyoming, salaries are closer to $50,000. That’s with numerous organizations supporting them, some whose purpose is to advocate for insurance billing and reimbursement issues.  Want a glimpse into how horribly bureaucratic and cumbersome the abyss of insurance billing can be?  Take a look at the ACA page on reimbursement

The investment to become a health coach is nowhere near what it takes to become a doctor, and yet they can be extremely skilled at what they do.  Most health coaches have a BA or BS degree, plus coaching certifications and work experience.  A financial target we give them is, “If you’re not making $100,000 per year – you’re doing something wrong.”  That amount, by the way, is money well-earned in a relatively stress-free business model that allows you to work from home while modeling a healthy, well-balanced lifestyle for your family and your clients.  

The Public 

People are no longer satisfied with just taking pills or chasing symptoms or managing disease.  Professional Health Coaching is providing the much-needed leadership in this area.  The public’s desire to be healthy and happy and enjoy their lives to the fullest is the driving force behind health coaching.  And they’re willing to pay out-of-pocket for disease reversing, health-building and lifestyle coaching and to take responsibility for their actions, while turning to insurance only for catastrophic and emergent issues.  Much health coaching freedom to own and operate your own successful business could be in jeopardy if the medical community takes over via CPT Codes and the insurance billing model.  

More Bureaucracy

As the Case Manager and Health Director for a wellness center in Southern California one of the jobs Reed Davis oversaw was insurance billing as well as rebilling.  As a health-service provider and businessperson, the whole idea of a third party getting between him and his customer was unsettling.  The truth is, you can do a lot of work under that system and never get paid, or you may end up having to accept whatever amount the third party decides to pay you, and get paid on their schedule, not yours.  The check may not come for weeks after the work is done, so to speak, so you’re less likely to put up a fuss when they have applied seemingly arbitrary discounts – and they know it.  For that and a lot of other reasons, we know “cash practice” is the best way to go. 

In the clinic, Reed became very familiar with applicable CPT Codes or procedure codes.  Coaches need to understand how this works.  In order to bill an insurance company for a procedure code you must first have a diagnosis code from a doctor or qualified healthcare provider (QHP), and the two have to match up according to company rules or you won’t get paid.  It seemed to me that “gatekeepers” at insurance companies could withhold payment for almost any reason, or even no reason.  Such gatekeepers are non-physicians working at insurance companies who, in essence, represent the company’s shareholders – not the patient, and certainly not the service provider.  

This was all back in the day, but it seemed if there was any way for them to delay, deny or discount the bill, they would.  In the industry there is even a nickname for this, “the three D’s of insurance!”  If you enter a diagnosis code and bill for a procedure that the insurance company determines doesn’t fit that diagnosis, the bill may be denied.  Another common reason for rejection, even if the company previously approved a procedure as it relates to a diagnosis, is the procedure is listed as “uncovered” for the current patient.  Remember, you don’t get paid for the diagnosis, you only get paid for a “covered” procedure that matches with their interpretation.  The insurance company can also approve the diagnosis and procedure code but decide to pay an amount less than the amount billed, even though the amount was reasonable and customary. Remember, the three D’s.

Let’s say you are a young doctor coming out of school, someone who can provide a diagnosis and bill an insurance company for certain CPT or procedure codes related to that diagnosis. Basically, the doctor provides the treatment and sends out a bill.  Then it’s up to the insurance company, whether you’re going to get paid or not, how much you’re going to get paid, and when you’re going to get paid.  All this takes place after you have already provided the service and, trust me on this, other than the original co-pay – you’ll never be able to collect a cent from the patient.  We determined long ago that, in an arms-length transaction between us and our customers (clients), we determined how much we would charge and when we’d get paid, preferably in advance.  In a free market, it’s the provider who determines his or her own fees and other terms of service.

The Problem

There is nothing wrong with working in a doctor’s office and it may be quite rewarding to be his or her health coach.  But it could also be quite restrictive, and the financial rewards won’t be the same as working for yourself.  The physician will provide a diagnosis and bill the patient’s insurance company for your time using the correct CPT codes, if they ever get approved.  

Moreover, implementing CPT Codes could potentially lead to a downgrade in how the public perceives health coaching.  Most Functional Health Coaches can do a lot more for a person than apply positive psychology to elicit compliance with a doctor’s orders with a nudge towards “diet and exercise”.   Unfortunately, while the most highly trained and skilled health coaches may not take these kinds of jobs, preferring to be independent, the public may not be aware of the differences.  Once again, you may hear a potential client say, “My insurance covers health coaching, why should I hire you when I can get it for free if I go to my physician?”

The Opportunity

We should celebrate any recognition and opportunity to integrate health coaching with medical services and both parties are wise to remain open to the possibilities on behalf of our patients and clients.  The public is ready, willing and (mostly) able to take advantage of any collaboration between the two disciplines and work together with respect for each other’s backyards.  Top-level health coaches trained through FDN know exactly where the lines are drawn and how to make sure they never cross them.  

Doctor’s don’t get to spend a lot of time with patients and there are often huge gaps between office visits lasting many weeks or months in which a lot can go wrong regarding health outcomes.  Health coaches can help bridge the gap and in turn should be controlling their own destiny. Who’s going to put the price on your time?  The doctor?  Certainly not the patient!  And not us if CPT Codes for health coaching are approved.  It will be the insurance companies.  And how will health coaching be perceived then?  Will it be just another “free” service provided at doctor’s offices? I guess we shall wait to see.  In the meantime, be careful what you wish for.

If you are ready to start building a successful career as an Independent Health Coach with the right lab training, tests and tools, then give us a call 858-842-3266 Ext. 1 or

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2020-08-12T20:53:47+00:00

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