Medicare and RD, obesity and nutritional therapy

[Guest guest]

ADA Meets with CMS Regarding Payment for Intensive Behavioral Counseling for

Obesity

ADA staff met last week with officials of the Centers for Medicare & Medicaid

Services who are tasked with developing the payment structure for the new

coverage for intensive behavioral counseling for obesity. CMS had made a

determination to 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 of at least 30 kg/m2. Based on

conversations with CMS, ADA was expecting this decision and is strategically

working through a variety of initiatives to position registered dietitians as

providers of medical nutrition therapy in other disease conditions.

The decision means registered dietitians can provide services as auxiliary

personnel in primary care settings and bill the service as " incident to " in

accordance with CMS guidelines (42 CFR section 410.26( or 410.27).

Last week, ADA met with CMS regarding RD-provided medical nutrition therapy and

detailed the amount of time and expertise necessary for its provision. ADA will

continue to work with CMS to ensure members are best able to take advantage of

the new opportunities that the obesity national coverage determination creates.

An email message from ADA President Sylvia A. Escott-Stump, MA, RD, LDN, and

Chief Executive Officer M. Babjak will be sent to members this week

with additional information and a call to action.

Read CMS' decision

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CMS:

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The Centers for Medicare and Medicaid Services (CMS) has determined the

following:

The evidence is adequate to conclude that intensive behavioral therapy for

obesity, defined as a body mass index (BMI) ¡Ý 30 kg/m2, is reasonable and

necessary for the prevention or early detection of illness or disability and is

appropriate for individuals entitled to benefits under Part A or enrolled under

Part B and is recommended with a grade of A or B by the U.S. Preventive Services

Task Force (USPSTF).

Intensive behavioral therapy for obesity consists of the following:

1. Screening for obesity in adults using measurement of BMI calculated by

dividing weight in kilograms by the square of height in meters (expressed in

kg/m2);

2. Dietary (nutritional) assessment; and

3. Intensive behavioral counseling and behavioral therapy to promote sustained

weight loss through high intensity interventions on diet and exercise.

The intensive behavioral intervention for obesity should be consistent with the

5-A framework that has been highlighted by the USPSTF:

1. Assess: Ask about/assess behavioral health risk(s) and factors affecting

choice of behavior change goals/methods.

2. Advise: Give clear, specific, and personalized behavior change advice,

including information about personal health harms and benefits.

3. Agree: Collaboratively select appropriate treatment goals and methods based

on the patient¡¯s interest in and willingness to change the behavior.

4. 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.

5. 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.

For Medicare beneficiaries with obesity, who are competent and alert at the time

that counseling is provided and whose counseling is furnished by a qualified

primary care physician or other primary care practitioner and in a primary care

setting, CMS covers:

* 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 meets

the 3kg weight loss requirement as discussed below.

At the six month visit, a reassessment of obesity and a determination of the

amount of weight loss must be performed. To be eligible for additional

face-to-face visits occurring once a month for an additional six months,

beneficiaries must have achieved a reduction in weight of at least 3kg over the

course of the first six months of intensive therapy. This determination must be

documented in the physician office records for applicable beneficiaries

consistent with usual practice. For beneficiaries who do not achieve a weight

loss of at least 3kg during the first six months of intensive therapy, a

reassessment of their readiness to change and BMI is appropriate after an

additional six month period.

For the purposes of this decision memorandum, a primary care setting is defined

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.

For the purposes of this decision memorandum a ¡°primary care physician¡± and

¡°primary care practitioner¡± will be defined consistent with existing sections

of the Social Security Act (¡ì1833(u)(6), ¡ì1833(x)(2)(A)(i)(I) and

¡ì1833(x)(2)(A)(i)(II)).

¡ì1833(u)

(6) Physician Defined.¡ªFor purposes of this paragraph, the term ¡°physician¡±

means a physician described in section 1861®(1)

<http://www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861-r> and the term

¡°primary care physician¡± means a physician who is identified in the available

data as a general practitioner, family practice practitioner, general internist,

or obstetrician or gynecologist.

¡ì1833(x)(2)(A)

Primary care practitioner¡ªThe term ¡°primary care practitioner¡± means an

individual¡ª

(i) who¡ª

(I) is a physician (as described in section 1861®(1)) who has a primary

specialty designation of family medicine, internal medicine, geriatric medicine,

or pediatric medicine; or

(II) is a nurse practitioner, clinical nurse specialist, or physician assistant

(as those terms are defined in section 1861(aa)(5)).

While this benefit is limited to primary care practitioners and primary care

settings, it does not preclude primary care practitioners from screening

beneficiaries for obesity and referring those who screen positive with a BMI ¡Ý

30 kg/m2 to other practitioners and/or settings for intensive multicomponent

counseling; however coverage remains only in the primary care setting.

S. Kalman PhD, RD, FACN

Director, BD - Nutrition & Applied Clinical Trials

Miami Research Associates

6141 Sunset Drive

Suite 301

Miami, FL. 33143

Direct -

Office ext. 5109

Fax

Email: dkalman@...

Web: www.miamiresearch.com

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