Cardiovascular Disease and Intensive Behavioral Therapy

Cardiovascular disease (CVD) is the leading cause of mortality in the United States. CVD, which comprises hypertension, coronary heart disease (such as myocardial infarction and angina pectoris), heart failure and stroke, is also the leading cause of hospitalizations. Although the overall adjusted mortality rate from heart disease has declined over the past decade, opportunities for improvement still exist.

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that Intensive Behavioral Therapy (IBT) for CVD is reasonable and necessary for the prevention or early detection of illness or disability, and is appropriate for individuals entitled to benefits under Medicare Part A or enrolled under Medicare Part B, and consists of components that are recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF).

Risk factors for CVD include:

• Being overweight
• Obesity
• Physical inactivity
• Diabetes
• Cigarette smoking
• High blood pressure
• High blood cholesterol
• Family history of myocardial infarction
• Older age

HCPCS code G0446 is used to report IBT for CVD services (annual face-to-face intensive behavioral therapy for cardiovascular disease). These services are also included as components of the Medicare Annual Wellness Visit.

Effective for claims with dates of service on or after November 8, 2011, CMS covers intensive behavioral therapy for CVD (referred to below as a CVD risk-reduction visit), which consists of the following three components:

• Encouraging aspirin use for the primary prevention of CVD when the benefits outweigh the risks for men age 45–79 years and women 55–79 years;
• Screening for high blood pressure in adults age 18 years and older; and
• Intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular- and diet-related chronic disease

Since only a small proportion of the Medicare population is under 45 years (men) or 55 years (women), the vast majority of beneficiaries should receive all three components. Intensive behavioral counseling to promote a healthy diet is broadly recommended to cover close to 100 percent of the population due to the prevalence of known risk factors. CMS covers one face-to-face CVD risk reduction visit per year for Medicare beneficiaries who are competent and alert at the time that counseling is provided, and whose counseling is furnished by a qualified primary care physician (PCP) or other primary care practitioner in a primary care setting.

The behavioral counseling intervention for aspirin use and healthy diet should be consistent with the Five A’s approach that has been adopted by the USPSTF to describe such services:

• Assess: Ask about and assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods
• Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits
• Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior
• Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate
• Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment

Medicare is concerned about the numver of primary care practitioners who may not be utilizing these services for Medicare beneficiaries. Adults who adhere to national guidelines for a healthy diet and physical activity have a lower cardiovascular morbidity and mortality than those who do not. All persons, regardless of CVD risk status, can accrue the health benefits of improved nutrition, health eating behaviors, and increased physical activity in order to promote a healthy diet and physical activity (USPSTF).

Note: For more information regarding the primary care setting, please refer to the resource page under the national coverage determination link.

Resources

• CMS MLN Booklet (PDF, 502 KB) titled "Annual Wellness Visit"
• CMS National Coverage Determination 210.11
• Intensive Behavioral Therapy (IBT) for Cardiovascular Disease
• MLN Matters Articles on Medicare-covered Preventive Services (PDF, 197 KB)
• US Preventive Services Task Force
• CVD Risk: Behavioral Counseling