Justified Billing Practices Can Improve Revenue for Weight-Focused Visits

ABSTRACT

Objective: To determine whether implementation of a care process for weight management, which included guidance on billing for weight-focused care, changed primary care practice procedure coding and revenue for these visits.

Study Design: PATHWEIGH, a cluster randomized, stepped-wedge pragmatic trial, was conducted across 56 primary care clinics in a single health system.

Methods: We identified patients receiving weight-focused care by provider use of weight-related diagnostic codes for billing recorded in the electronic health record (EHR). EHR-derived procedure codes for billing were used to examine coding practices for these visits during usual care and intervention phases. Practice revenue for these encounters was calculated based on published mean allowed amounts from paid claims submitted by commercial insurance, Medicare, and Medicaid payers to the Colorado All Payer Claims Database.

Results: Use of 55 unique code combinations was significantly different (P < .001) between the usual care and intervention phases. The proportion of weight-focused visits with multiple procedure codes recorded for billing was 14% in the usual care phase vs 19% in the intervention phase, with a shift toward the use of higher-level evaluation and management codes (99214/99215 vs 99213) during the intervention phase. Changes in code combinations resulted in higher mean reimbursements for both initial and subsequent weight-focused visits during the intervention phase compared with usual care. These coding changes increased revenue for the 124,621 weight-focused visits in the intervention phase by $1,071,293.

Conclusions: Having a care process for weight management in primary care that includes guidance for billing can increase primary care practice revenue for weight-focused care.

Am J Manag Care. 2026;32(8):In Press

Takeaway Points

The financial viability of routine weight management in primary care is essential. PATHWEIGH, a novel care process for weight management, was implemented in 56 primary care practices and mitigated weight gain across the practices’ adult patient population with a body mass index greater than or equal to 25. Analysis of procedure codes identified in electronic health records for billing was conducted within this pragmatic trial and sought to assess whether having a care process in place for weight management, which included guidance on billing for weight-focused care, changed coding practices and improved revenue for this care.

Major findings from a pre-/post analysis include the following:

• After implementation of a care process for weight management, primary care procedure coding changed significantly, with increased use of higher-level evaluation and management codes and multiple procedure codes.
• Differences in procedure coding practices resulted in greater revenue from delivering weight-focused care.
• Our findings are highly relevant to primary care practices considering implementing care processes for weight management.

Delivery of weight-focused care in primary care settings has been hampered by relatively low reimbursement provided by payers.¹ PATHWEIGH, a novel care process for weight management, mitigated weight gain in adults with a body mass index (BMI) greater than or equal to 25 across 56 Colorado primary care practices studied in a pragmatic trial (NCT04678752).^2,3 The care process consisted of modifications to the electronic health record (EHR) to facilitate weight management and implementation strategies to support its use, which included guidance on coding and billing for weight-focused care. The current analysis compared procedure codes used for billing for weight-focused visits during the usual care and intervention phases of the trial.

METHODS

Weight-focused visits from March 2020 to September 2024 were identified primarily by use of International Statistical Classification of Diseases, Tenth Revision diagnostic codes (E66-E.66.9, Z68.25-45). Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes were recorded in the EHR for weight-focused visits, along with unique code combinations, and were totaled for both phases. Payer type for each visit was categorized as commercial, Medicare, Medicaid, or self-pay. We used Fisher exact and Pearson χ² tests to assess differences in code combinations and payer mix for initial and subsequent visits in each phase.

To estimate potential revenue from delivering weight-focused care, we used mean allowed amounts paid to Colorado physicians in 2022 from the Center for Improving Value in Health Care (CIVHC). Colorado Senate Bill 22-068, passed in 2022, authorized the CIVHC, administrator of the Colorado All Payer Claims Database, to publish payments for all CPT and HCPCS codes. To isolate the effects of coding changes from payer mix shifts across phases, we calculated mean allowed amounts by payer type and by mean payer mix across all weight-focused visits in both phases, assigning self-pay visits commercial values. Results are reported in 2022 US$.

RESULTS

Of 180,726 weight-focused visits, 56,105 and 124,621 visits occurred during the usual care and intervention phases, respectively. Providers used 22 CPT/HCPCS codes in 55 unique combinations. Visits billed with multiple codes increased from 14% in the usual care phase to 19% in the intervention phase. Use of higher-level evaluation and management codes (eg, 99214 and 99215 vs 99213) increased during the intervention phase. Behavioral counseling for obesity (G0447) was used in approximately 1% of visits in both phases.

Table 1 lists the 12 most prevalent codes and the percentage of visits using each code combination for initial and subsequent visits across phases. Use of the 55 unique combinations was significantly different (P < .001) for both initial and subsequent visits between the usual care and intervention phases. The mean allowed amounts for traditional Medicare for 2022 claims in the Colorado All Payer Claims Database for the different code combinations are shown in Table 1.

Payer mix also differed significantly between phases and between initial and subsequent visits (P < .001) (Table 2). Mean allowed amounts were higher during the intervention phase across all payer categories (Table 2). Mean payer mix revenue from weight-focused visits increased from $208.30 to $217.51 for initial visits and from $202.71 to $210.76 for subsequent visits.

DISCUSSION

Financial viability is often cited as a barrier to providing weight management care in primary care settings.^4,5 Results from the PATHWEIGH trial challenge this contention; during the trial, 124,621 weight-focused visits were delivered after implementing a care process that included guidance on coding and billing. Coding changes between phases increased revenue for these weight-focused visits by $1,071,293 in the intervention phase. An important caveat is that guideline revisions for CPT codes 99202 to 99215 implemented on January 1, 2021, allowed coding based on total time or medical decision-making, replacing prior requirements. If practices phased in this guidance during the trial, it may confound the observed changes in procedure coding attributed to PATHWEIGH.

Author Affiliations: Division of Endocrinology, Metabolism, and Diabetes (LP), Division of Health Care Policy and Research (RMG), and Department of Family Medicine (LP, CR, JSH, RMG), School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Epidemiology, Colorado School of Public Health (LP), Aurora, CO; Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus (JSH, RMG), Aurora, CO.

Source of Funding: National Institutes of Health (1R18DK127003).

Author Disclosures: Dr Perreault has received grant funding from the National Institutes of Health and honoraria, lecture fees, and consultancy or advisory fees from Boehringer Ingelheim, Eli Lilly and Company, and Novo Nordisk. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LP, JSH, RMG); acquisition of data (CR); analysis and interpretation of data (LP, CR, RMG); drafting of the manuscript (LP, CR, JSH); critical revision of the manuscript for important intellectual content (CR, JSH, RMG); statistical analysis (CR); provision of patients or study materials (LP); obtaining funding (LP, JSH); administrative, technical, or logistic support (LP); and supervision (LP, JSH).

Address Correspondence to: Leigh Perreault, MD, University of Colorado Anschutz Medical Campus, PO Box 6511, Mailstop F8016, Aurora, CO 80045. Email: leigh.perreault@cuanschutz.edu.

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