Re: Fw: CMS's Final Decision on Intensive Behavioral Counseling for Obesity

December 7, 2011

I love how they put it back on us. Continue to market yourself and your

services to primary care providers.

> **

>

> FYI

>

> ----------

> Holly Lee Brewer, MS RD CDE

> Pediatric Dietitian, Diabetes Educator

> Medical Nutrition Therapist, Las Vegas, NV

>

> Maj Holly Brewer, USAFR BSC http://hollyinbalad.blogspot.com

> 301st MDS, NAS JRB Fort Worth (Carswell), TX

> Joint Base Balad, Iraq (Jan-Jul 2009)

>

> ----- Forwarded Message -----

> >

> >To: hlbrewer@...

> >Sent: Wednesday, December 7, 2011 1:20 PM

> >Subject: CMS's Final Decision on Intensive Behavioral Counseling for

> Obesity

> >

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> >CMS's Final Decision on Intensive Behavioral Counseling for Obesity and

> How it Affects RD's

> >Dear Holly,

> >

> >The American Dietetic Association understands and shares members'

> concerns about the announcement by the Centers for Medicare & Medicaid

> Services (CMS) on Tuesday, November 29 about their decision to cover

> Intensive Behavioral Counseling for Obesity for eligible Medicare

> beneficiaries. We'd like to share the following information in an effort to

> answer member questions about this decision and what it means for

> Registered Dietitians (RDs).

> >

> >How did CMS make this decision?

> >

> >Through the Medicare Improvements for Patients and Providers Act (MIPPA),

> CMS has the authority to add coverage of additional preventive services

> under a process called a National Coverage Determination. This process is

> not a legislative one, meaning the decision is not made through Congress.

> Rather, CMS is the decision-making body. CMS is required to evaluate

> relevant clinical evidence to determine whether or not the proposed service

> meets three criteria:

> > 1. Reasonable and necessary for the prevention or early detection of

> illness or disability;

> > 2. Is recommended with a Grade A or B by the US Preventive Services Task

> Force; and

> > 3. Is appropriate for individuals entitled to benefits under Part A or

> enrolled under Part B of the Medicare program.

> >

> >The process includes two opportunities for public comment. On March 11,

> 2011 CMS announced it was opening a national coverage analysis for

> Intensive Behavioral Therapy for Obesity with a 30-day public comment

> period. On August 31, 2011 CMS issued its proposed decision memorandum with

> a 30-day comment period.

> >

> >Was ADA involved?

> >

> >Definitely! ADA offered comments during both public comment periods.

> These comments incorporated input from members with expertise in weight

> management services and were reviewed and approved by member leaders. Visit

> http://www.eatright.org/mnt/ and scroll down to " Medicare MNT Coverage

> Expansion " to read more. In November ADA also met with CMS staff, along

> with other members of the Obesity Care Coalition, to advocate for inclusion

> of RDs in the proposed benefit.

> >

> >What exactly did CMS decide to cover?

> >

> >CMS determined it will cover screening and intensive behavioral

> counseling for obesity by primary care providers in settings such as

> physicians' offices for Medicare beneficiaries with a body mass index (BMI)

> > 30 kg/m2. Specifically, Medicare will cover:

> >* One face-to-face visit every week for the first month;

> >* One face-to-face visit every other week for months 2-6;

> >* One face-to-face visit every month for months 7-12, if the beneficiary

> has achieved a reduction in weight of at least 3kg over the course of the

> first six months of intensive therapy.

> >

> >The service must be furnished by a " qualified primary care physician or

> other primary care practitioner and in a primary care setting. " CMS refers

> to the Social Security Act for its definition of a " qualified primary care

> physician " to mean a physician who is a general practitioner, family

> practice practitioner, general internist or obstetrician or gynecologist.

> In similar manner, CMS defines " primary care practitioner " as a physician

> with a primary specialty designation of family medicine, internal medicine,

> geriatric medicine or pediatric medicine or a nurse practitioner, clinical

> nurse specialist, or physician assistant in accordance with the Social

> Security Act.

> >

> >Lastly, the service must be furnished in the primary care setting. CMS

> defines a primary care setting " as one in which there is provision of

> integrated, accessible health care services by clinicians who are

> accountable for addressing a large majority of personal health care needs,

> developing a sustained partnership with patients, and practicing in the

> context of family and community. Emergency departments, inpatient hospital

> settings, ambulatory surgical centers, independent diagnostic testing

> facilities, skilled nursing facilities, inpatient rehabilitation facilities

> and hospices are not considered primary care settings under this

> definition. "

> >

> >What was the rationale behind CMS's decision to not include RDs as

> providers of these services?

> >

> >Based on CMS's responses to public comments in this final decision memo

> as well as the one issued earlier this month for Intensive Behavioral

> Counseling for Cardiovascular Disease, it appears that CMS excluded RDs for

> two reasons:

> > 1. CMS believes it lacks the statutory authority to include RDs as

> providers outside of diabetes and end stage renal disease; and

> > 2. CMS believes it is important that preventive services be furnished in

> a coordinated approach as part of a comprehensive prevention plan within

> the context of the patient's total health care. As such, they believe

> primary care practitioners are best qualified to offer care in this context.

> >

> >How will these services be paid and when does the benefit become

> effective?

> >

> >The answers to these questions have yet to be determined. CMS is in the

> process of establishing codes and developing the claims processing

> instructions for this NCD.

> >

> >What do we do now?

> >

> >As individual practitioners:

> >RDs as providers of nutrition services have 2 options when it comes to

> obesity services for Part B Medicare beneficiaries:

> > 1. The CMS decision memorandum does state that the new benefit does not

> preclude primary care practitioners from referring eligible beneficiaries

> to other practitioners and/or settings for counseling; however coverage

> remains only in the primary care setting. So RDs can receive referrals

> for these services, but the Medicare beneficiary would need to be informed

> prior to providing the service that it is not covered by Medicare and they

> would be required to pay out of pocket for the service.

> > 2. The CMS decision memorandum also states that in the primary care

> office setting and primary care hospital outpatient setting, Medicare may

> cover these services when furnished by auxiliary personnel (e.g., RDs) and

> billed as " incident to " services in accordance with 42 CFR section

> 410.26( or 410.27, meaning:

> > 1. There is direct physician supervision of auxiliary personnel (the

> physician must be present in the office suite and immediately available to

> provide assistance and direction throughout the time the service is being

> provided).

> > 2. " Auxiliary personnel " means any individual who is acting under the

> supervision of a physician, regardless of whether the individual is an

> employee, leased employee, or independent contractor of the physician, or

> of the legal entity that employs or contracts with the physician.

> >Note: Medicare Part B MNT services for diabetes and non-dialysis renal

> disease cannot be billed as " incident to " services since they are

> recognized as a separate benefit category.

> >

> >We recognize that both of these options fall short of the ideal scenario.

> However, as healthcare delivery and payment models move away from

> fee-for-service to bundled payment models (such as Patient-Centered Medical

> Homes and Accountable Care Organizations), now is a good time for RDs to

> align themselves with primary care practitioners in new ways. Continue to

> market yourself and your services to both primary care practitioners and

> Medicare beneficiaries to create demand for your services and demonstrate

> the value you bring to a comprehensive and coordinated model of care. As an

> RD, you can positively impact a practice's bottom line by helping patients

> and the practice achieve positive clinical outcomes. Most importantly, you

> can collect, report, and publish outcomes data to strengthen the foundation

> of clinical evidence used by CMS and others in making coverage decisions.

> >

> >As ADA:

> >

> >The Nutrition Services Coverage team and the Policy Initiatives and

> Advocacy team are strategically working to position RDs as providers of MNT

> in other disease conditions through a variety of initiatives. With this

> new insight into CMS's approach to expanding coverage, we are exploring

> potential strategies on both the legislative and regulatory fronts. We will

> continue to share information with members through all available

> communication channels.

> >

> >Click here to read the full CMS Final Decision Memorandum.

> >

> >Nutrition Services Coverage Team

> >Reimburse@...

> >

> >Nevada Dietetic Association

> >www.NevadaRD.com

> >NevadaRD@...

> >

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December 7, 2011