Commit to Fit! Weight Assessment: Child (Under Age 18) DEMOGRAPHICS (To be filled out by the patient or patient guardian) First & Last Name: DOB: Gender (Circle One): M F Address: Preferred Phone: Home Cell Work (Circle One) Race/Ethnicity (Circle One): White African American American Indian Asian Indian Japanese Chinese Other (Please List): Language (Circle One): English Spanish Other (Please List): BMI MEASUREMENT (To be filled out by the physician) Date: Height: Weight: BMI: = weight (lb) / [height (in)] 2 x 703 BMI Classification (Check One): Underweight (BMI <5th percentile) Healthy Weight (5th percentile to 85th percentile) Overweight (85th percentile to <95th percentile) Obese (BMI 95th percentile) HEALTHY BEHAVIORS ASSESSMENT (To be filled out by the patient or patient guardian) How many servings of fruits and vegetables do you eat a day? How many times a week do you eat dinner at the table with your family? How many times a week do you eat breakfast? How many tmes a week do you eat takeout or fast food? How many hours a day do you watch TV/movies or sit and play video/computer games? Do you have a TV in your room where you sleep? Do you have a computer in your room where you sleep? How many hours of sleep do you get per night? How much time a day do you spend in active play (faster breathing/sweating)? How many 12-ounce servings of the following do you drink a day (12 oz. = 1 can of soda or pop): 100% Juice: Fruit or Sports Drinks: Soda or Punch: Water: Whole or 2% milk: 1% or Skim Milk: Please rate your stress level below (Circle a Number): Little or no stress PHYSICIAN ADDITIONAL NOTES A great deal of stress. Physician Signature: Patient/Guardian Signature: Date: Date: www.commit2fit.com HEALTH-8B4 weightassessement.child.062513ar
Commit to Fit! Weight Assessment: Adult (18 and Over) DEMOGRAPHICS (To be filled out by the patient) First & Last Name: DOB: Gender (Circle One): M F Address: Preferred Phone: Home Cell Work (Circle One) Race/Ethnicity (Circle One): White African American American Indian Asian Indian Japanese Chinese Other (Please List): Language (Circle One): English Spanish Other (Please List): BMI MEASUREMENT (To be filled out by the physician) Date: Height: Weight: BMI: = weight (lb) / [height (in)] 2 x 703 BMI Classification (Check One): Underweight (BMI <18.5) Healthy Weight (BMI 18.5-24.9) Overweight (BMI 25.0-29.9) Obese (BMI>30.0) HEALTHY BEHAVIORS ASSESSMENT (To be filled out by the patient) How many servings of fruits and vegetables do you eat a day? How many times a week do you eat breakfast? How many times a week do you eat takeout or fast food? How many hours a day do you watch TV/movies or sit and play video/computer games? Do you have a TV in your room where you sleep? Do you have a computer in your room where you sleep? How many hours of sleep do you get per night? How much time a day do you spend in active play (faster breathing/sweating)? How many 12-ounce servings of the following do you drink a day (12 oz. = 1 can of soda or pop): 100% Juice: Fruit or Sports Drinks: Soda or Punch: Water: Whole or 2% Milk: 1% or Skim Milk: Please rate your stress level below (Circle a Number): Little or no stress PHYSICIAN ADDITIONAL NOTES A great deal of stress. Physician Signature: Patient Signature: Date: Date: www.commit2fit.com HEALTH-8B4 weightassessement.adult.062513ar
Child Healthy Weight Plan (Child s Name) (Caregiver s Name) SETTING A GOAL (to be filled out by caregiver and child together) Here are some things other people have decided to do for their health. I would like to set goal(s) to: Eat at least 5 servings of fruit/vegetables a day Avoid pop and other sugary drinks Get at least 60 minutes of physical activity every day Limit screen time (computers, video games and TV) Eat healthy dinners with my family regularly Eat or drink 3 servings of dairy daily Get enough sleep Other: ACHIEVING MY GOAL (to be filled out by caregiver and child together) 1. How important is it to me to make this change? (Circle One) Not at all important Extremely important 2. What might make it difficult for me to achieve my goal (what are the barriers)?. 3. How confident am I that I can carry out this plan? (Circle One): Not at all confident Extremely confident 4. I agree to this plan of action and will review my plan and progress on with by (Date). REFERRALS (to be filled out by caregiver only) I need more information about how to improve my child s health! I want him or her to: Register as a user on www.commit2fit.com, and log onto the website daily with me. See their primary care doctor, (Name) by. See a dietician or nutritionist to talk about healthy eating. Be referred to community agencies where he/she can exercise. See a therapist or social work to discuss his/her emotional and social health. You can use various Commit to Fit! tools based on the patients identified goals. See the the Supplemental Materials section for a complete list of tools. All patients should register as users on the website, as it addresses all health goals. I give my permission to forward this information about my child s health assessment and plan to the health professional(s) I want him/her to see. Signature of Parent/Guardian: Date: HEALTH-8B4 hwplan.child.version.062813ar
Adult Healthy Weight Plan (Name) SETTING A GOAL Here are some things other people have decided to do for their health. I would like to set goal(s) to: Eat at least 5 servings of fruit/vegetables a day Avoid sugar-sweetened beverages Get at least 60 minutes of physical activity every day Limit screen time (computers, video games and TV) Monitor my weight status regularly Manage my stress Get enough sleep Other: ACHIEVING MY GOAL 1. How important is it to me to make this change? (Circle One) Not at all important Extremely important 2. What might make it difficult for me to achieve my goal (what are the barriers)?. You can use various Commit to Fit! tools based on the patients identified goals. See the the Supplemental Materials section for a complete list of tools. 3. Steps I will take to make this change (include the what, when, how and with whom): a.. b.. c.. d.. 4. How confident am I that I can carry out this plan? (Circle One): Not at all confident Extremely confident 5. Information or support I might need in accomplishing my goal:. 6. I will know my plan is working when:. 7. I will celebrate my success by:. 8. I agree to this plan of action and will review my plan and progress on with REFERRALS by (Date). I need more information about how to improve my health! I want to: Register as a user on www.commit2fit.com, and log onto the website daily. See my primary care doctor, (Name) by. See a dietician or nutritionist to talk about healthy eating. Be referred to community agencies where I can exercise. See a therapist or social work to discuss my emotional and social health. All patients should register as users on the website, as it addresses all health goals. I give my permission to forward this information about my health assessment and my plan to the health professional(s) I want to see. Signature of Individual: Date: HEALTH-8B4 hwplan.adult.revised.070213ar
Reimbursement for Obesity Counseling Using Commit to Fit! Physician s Toolkit The following information represents physician reimbursement options when utilizing the Commit to Fit! Weight Assessment and Healthy Weight Plan for obesity counseling. Medicare Coverage CMS Guidelines for Obesity Counseling Coverage & Services Obesity Counseling o Face-to-Face o Provided by a primary care physician o Provided in a primary care setting o Minimum 15 minute sessions o Patient BMI 30 o Maximum of 22 visits allocated in a 12 month period 1 visit per week in first month 1 visit every other week in months 2-6 1 visit every month for months 7-12 if patient has met the 6.6 lb. weight loss requirement in first six months ICD-9 Diagnostic Code Other Medicare Coverage for Obesity Counseling V85.30 V85.40 series NOTE: The V85 series code for obesity must be included in a patient s diagnosis in order to use the G0477 obesity counseling code CPT/HCPCS Code G0447 NOTE: G0477 may be billed in addition to a regular E & M coded visit (in this case patient would not have a copay for these services) Reimbursement Amount $24.50 Both Blue Cross Blue Shield of Michigan and HealthPlus of Michigan Medicare Plans follow CMS guidelines and offer the same reimbursement. Commercial Insurance Coverage for Obesity Counseling Insurer Specific Plan ICD-9 Diagnostic Code Blue Cross Blue Shield of Michigan HealthPlus of Michigan McLaren Health Plan Commercial Plan: Coverage varies depending on group - if covered, copays may apply to services provided by outof-network providers Follows CMS Guidelines if covered, copays may apply to services provided by outof-network providers Currently does not offer reimbursement for obesity counseling CPT/HCPCS Code Reimbursement Amount Physician s office should consult BCBSM for billing and reimbursement amounts for commercial clients. V85.30 V85.40 series G0447 $21.25 N/A N/A N/A