Coverage, Coding and Billing for Pediatric Obesity Services


By Jessica Larson, MD, Co-Chair of MNAAP’s Pediatric Obesity Work Group and Pediatrician at Fairview Clinic in Elk River; Russ Kuzel, MD, Senior VP and CMO at UCare; and Megan Ellingson, MHA, Consultant to the Minneapolis Health Department

In 2012 the Minnesota Partnership on Pediatric Obesity Care and Coverage (MPPOCC) set out to better understand clinics’ experiences obtaining reimbursement for pediatric obesity services, and to provide guidance on best practices and coverage.

Led by MNAAP and the Minnesota Council of Health Plans, this group is dedicated to improving pediatric obesity care and coverage by identifying effective referral pathways and advocating for reimbursement for necessary, evidence-based services.

MPPOCC participants include pediatricians, health plan and public health representatives, and community-based service providers, who are engaging in regular conversations to ensure evidence-based services are covered — and to brainstorm ways to fill in gaps when necessary.

While public insurance programs provide a standard benefit set, private insurance coverage can vary. When in doubt, ask parents to call the number on the back of their insurance card.

The MPPOCC is also working on innovative strategies to address pediatric obesity in clinic and community settings. Some clinics don’t currently offer intensive pediatric obesity services in-house, and some community-based programs are showing good results. This provides an interesting opportunity for partnerships.

The MPPOCC is seeking more clarification on how reimbursement can flow to community-based family programs, and has developed a “discussion guide” to link health plans, clinics and community service providers on the topic of service innovations. Figuring out how to support clinic and community linkages long-term will help families engage in and experience successes they can sustain.

In 2014 Minnesota Community Measurement began tracking clinics’ provision of physical activity and nutrition counseling services for children ages 3-17 with BMI greater than the 85th percentile. Providers are playing an important role in addressing the obesity epidemic by collecting and reporting BMI; counseling patients on physical activity and nutrition; identifying and providing follow-up services; and referring patients to community-based programs that meet their needs.

For more information, the MPPOCC developed a fact sheet detailing their findings and providing links to further
resources. Visit obesitycoding.html

For more information visit

Insurance coverage follows best practice recommendations of the U.S. Preventive Services Task Force for overweight and obesity services, including:

• Screening, education, assessments, counseling, surgery and other medically necessary services (some limitations and prior authorization requirements may apply).

• Comprehensive, intensive behavioral interventions to promote improvement in weight status, including: (1) counseling and other interventions targeting diet and physical activity; (2) parental involvement (for younger children); and (3) at least 25 hours contact with child and/or family over 6 months.

• Visits with primary care and specialty clinicians, dieticians, nurses, counselors and Community Health Workers for the purpose of obesity management.

Key findings of the MPPOCC’s work to date:

• Providers and clinic staff can use the obesity
diagnosis code alone; children do not need to have an existing co-morbidity such as diabetes in order to have clinical services covered.

• Billing staff are encouraged to follow-up on denied claims.

• Services for children on public programs are covered without copays or coinsurance.

Annual Sponsors

Children's Minnesota
Gillette Children's
Hennepin Healthcare
University of Minnesota Health
Essentia Health
Mayo Clinic
Shriners Healthcare for Children-Twin Cities