Guide To New Health Coach CPT Codes

Will insurance payers now reimburse for claims submitted by health coaches?

The AMA maintains three main categories of CPT® codes: I, II, and III.

The Health and Well-Being Coaching Codes are approved as Category III, which are considered temporary. According to the AMA, category III “emerging technology” codes are created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

The approved Health and Well-Being Coaching Category III CPT® codes will be in effect for five years but are renewable. These temporary codes are intended to support the wide utilization and data collection, with and without reimbursement, required for AMA approval of Category 1 codes.

Reimbursement by payers of Category III codes is optional starting January 1, 2020. However, insurance payers typically wait until codes have Category I approval before they will provide reimbursement. The AMA has yet to even discuss reimbursement amounts for these CPT® codes, and as so, it is unlikely that reimbursement for health coaches can be expected in the immediate future.

Furthermore, the AMA defines a health coach as a “non-physician health care professional certified by NBHWC or the NCHEC.” In order for a health coach to be able to utilize these new codes, they will need to be certified by either of these professional organizations. The AMA will continue to discuss which professionals (and when), can begin utilizing the Category III codes.

The CPT® Editorial Panel, appointed by the AMA Board of Trustees, is responsible for maintaining and updating the CPT® code set. The CPT® Editorial Panel is an “independent group of expert volunteers representing various sectors of the healthcare industry.” Their role is to ensure that code changes undergo evidence-based review and meet specific criteria.

While the new health coaching CPT® codes are approved as Category III codes, they have the potential to be updated as Category I codes in the future. To be revised as a Category I CPT® Code, according to AMA criteria, there will need to be sufficient evidence that health coaching services are used across the United States, with frequency, and have clinical efficacy.

The board reportedly will monitor use of the new codes by national board-certified health and wellness coaches to assess how effective nutrition coaching is as a part of the healthcare system.

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What do these new CPT® codes mean for the health coaching industry?

Many professional health coaching organizations are celebrating this approval as a major breakthrough for the health coaching industry. The changes are viewed as a step towards establishing health coaching as not only a recognized profession, but as a “respected, esteemed career path for those who want to change lives.” The Institute of Integrative Nutrition (IIN) is hopeful that these changes will open up job opportunities for health coaches, and will increase access to health coaching support. What we can expect to see from the addition of these new CPT® codes, is the potential for additional growth in insurance coverage for health coaching in future years.

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At present, although the approval of the codes is significant, there is much unresolved about utilizing the codes in practice. According to Leigh-Ann Webster, Executive Director of NBC-HWC, there are many questions that still need to be clarified by the AMA, including ways that data collection will be implemented and how to best utilize these new codes. NBHWC is putting together a FAQ guide to help better clarify these questions, and expect more information to come from AMA in February and March of 2020.

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