Re: CMS coverage for Obesity counseling and CVD risk reduction

[Guest guest]

That does sound very exciting Carla. And you created the online program? Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing From: [mailto: ] On Behalf Of Carla GibsonSent: Thursday, December 01, 2011 12:10 AMTo: Subject: CMS coverage for Obesity counseling and CVD risk reduction This kind of relates to the thread on Nurse Billing Question but veers off a bit- thus the new thread.. I think most of you are probably aware that CMS is now going to cover a once a year CVD risk reduction visit and as of today, have also announced coverage for pretty frequent obesity counseling visits- even weekly for a few months. For patients deemed to be obese based on body mass index measures, the benefit would include one face-to-face counseling visit each week for one month and one face-to-face counseling visit every other week for an additional five months.Medicare patients who lose at least 6.6 pounds (3 kilograms) during the first six months of counseling would be eligible to receive addition face-to-face counseling once a month for an additional six months for up to a total of 12 months of counseling, the agency said.No word yet on level of reimbursement and I'm not clear if the counseling can be delegated to an office nurse or nutritionist-type person yet. But, still, kind of exciting.I've been planning on ramping up my work with patients regarding obesity and this is very timely for me. I've spent the last 18 months implementing an online program for patients that covers all the topics I want them to know about healthy food choices, portions, how to plan and prepare ahead... helping them make habit changes slowly over time. And just as important, the program incorporates information on improving sleep, optimizing one's response to stress, and the basics on increasing activity/exercise. The online program has forums for patients to interact anonymously with each other if desired- about half choose to do this and really found it helpful to be engaged...much like mentioned in regard to her group visits. I will now start incorporating a series of office visits with those patients to strengthen the information with them personally, provide some accountability and individualize advice. Planned to use diagnosis codes like impaired fasting glucose, HTN, Hyperlipidemia, etc... for the office visits- or just cash visits if necessary when no problem codes applied. But now, at least for obese Medicare patients, these visits will be covered- and with the online program providing almost daily interaction via email and the website, their chance of success is even higher. Even without the individual visits, about a third of the participants in the online program reported losing lost between 10-45 pounds over the one year program. It will be interesting to see if there will be a difference in success rates with in-office visits to complement the program.Here are the links if you have not seen them yet:Cardiovascular risk reduction:http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=248Obesity:http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=253 & ver=4 & NcaName=Intensive+Behavioral+Therapy+for+Obesity & TimeFrame=7 & DocType=All & bc=AgAAYAAAIAAA & Carla Gibson FNPMissoula, MT

[Guest guest]

Yes...I wrote the content and set up the website-- first out of frustration in not being able to deliver all that content to patients in a way they could receive it effectively via office visits that were reimbursable, but also because I like creating productions like this. In retrospect, it was a big undertaking but well worth it in the long run. Like probably all of our practices, mine is full of patients heading the wrong direction metabolically and for some reason, perhaps selection bias in those who chose to participate, the online program has been more successful in helping them make changes to their risk profiles than time with me in the office has been. I hope that crafting the series of office visits to match/complement the content of the online program will be even more effective.

Carla Gibson FNPMissoula, MT To: Sent: Wednesday, November 30, 2011 10:30 PM Subject: RE: CMS coverage for Obesity counseling and CVD risk reduction

That does sound very exciting Carla. And you created the online program? Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing From: [mailto: ] On Behalf Of Carla GibsonSent:

Thursday, December 01, 2011 12:10 AMTo: Subject: CMS coverage for Obesity counseling and CVD risk reduction This kind of relates to the thread on Nurse Billing Question but veers off a bit- thus the new thread.. I think most of you are probably aware that CMS is now going to cover a once a year CVD risk reduction visit and as of today, have also announced coverage for pretty frequent obesity counseling visits- even weekly for a few months. For patients deemed to be obese based on body mass index measures, the benefit would include one face-to-face counseling visit each week for one month and one face-to-face counseling visit every other week for an additional five months.Medicare patients who lose at least 6.6 pounds (3 kilograms) during the first six months of counseling would be eligible to receive addition face-to-face

counseling once a month for an additional six months for up to a total of 12 months of counseling, the agency said.No word yet on level of reimbursement and I'm not clear if the counseling can be delegated to an office nurse or nutritionist-type person yet. But, still, kind of exciting.I've been planning on ramping up my work with patients regarding obesity and this is very timely for me. I've spent the last 18 months implementing an online program for patients that covers all the topics I want them to know about healthy food choices, portions, how to plan and prepare ahead... helping them make habit changes slowly over time. And just as important, the program incorporates information on improving sleep, optimizing one's response to stress, and the basics on increasing

activity/exercise. The online program has forums for patients to interact anonymously with each other if desired- about half choose to do this and really found it helpful to be engaged...much like mentioned in regard to her group visits. I will now start incorporating a series of office visits with those patients to strengthen the information with them personally, provide some accountability and individualize advice. Planned to use diagnosis codes like impaired fasting glucose, HTN, Hyperlipidemia, etc... for the office visits- or just cash visits if necessary when no problem codes applied. But now, at least for obese Medicare patients, these visits will be covered- and with the online program providing almost daily interaction via email and the website, their chance of success is even higher. Even without the individual visits, about a third of the participants in the online program reported losing lost between 10-45 pounds over

the one year program. It will be interesting to see if there will be a difference in success rates with in-office visits to complement the program.Here are the links if you have not seen them yet:Cardiovascular risk reduction:http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=248Obesity:http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=253 & ver=4 & NcaName=Intensive+Behavioral+Therapy+for+Obesity & TimeFrame=7 & DocType=All & bc=AgAAYAAAIAAA & Carla Gibson FNPMissoula, MT

[Guest guest]

> No

> word yet on level of reimbursement and I'm not clear if the counseling

> can be delegated to an office nurse or nutritionist-type person yet.

Thanks for pointing this out, Carla. The link you provide on the obesity

counseling program indicates that the counseling must be " furnished by a

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

primary care setting " . Those are strictly defined. I really wish I could work

with the nutrition counselor who shares space with me on this, but it doesn't

look that would work.

Haresch

[Guest guest]

,I took the time to read the small print further down in the decision memo.... here is the language:"This decision covers intensive behavioral therapy for obesity when furnished in primary care settings, as described in section I. In the primary care office setting, Medicare may cover these services when billed by the primary care physician or practitioner and furnished by auxiliary personnel under the conditions specified under our regulation at 42 CFR section 410.26( (conditions for services and supplies incident to a physician’s professional service). "Incident to services can be billed by the physician (or even an NP) for services provided by their employees

as defined by CMS. Here are those rules:Requirements

All the following requirements must be met before an NPP may bill

under the "incident to" provision:

The NPP must be an employee of the physician;The initial visit (for that condition) must be performed by

the physician .This does not mean that on each occasion of an

incidental service performed by an NPP, that the patient must

also see the physician. It does mean there must have been a

direct, personal, professional service furnished by the physician

to initiate the course of treatment of which the services being

performed by the NPP is an incidental part.There must be direct personal supervision by the physician as

an integral part of the physician's personal in-office service.

The physician must be physically present in the same office suite

and be immediately available to render assistance if that becomes

necessary;The physician has an active part in the ongoing care of the

patient. Subsequent services by the physician must be of a

frequency that reflects his/her continuing active participation

in, and management of, the course of the treatment.Hope this helps! It seems like a HUGE opportunity. Assuming they set reasonable reimbursement rates. If I remember correctly , the nutritionist in your space is not your employee? That set-up seems like it does not meet the incident to guidelines. If not, and you are looking for an easy counseling package to implement, I'm working on tweaking my program to meet these guidelines and will offer it soon to other providers. You can email me off list. Apologies if this is too much of a "vendor" plug.Carla Gibson FNPMissoula, MT To: Sent: Thursday, December 1, 2011 8:14 PM Subject: Re: CMS coverage for Obesity counseling and CVD risk reduction

> No

> word yet on level of reimbursement and I'm not clear if the counseling

> can be delegated to an office nurse or nutritionist-type person yet.

Thanks for pointing this out, Carla. The link you provide on the obesity counseling program indicates that the counseling must be "furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting". Those are strictly defined. I really wish I could work with the nutrition counselor who shares space with me on this, but it doesn't look that would work.

Haresch

[Guest guest]

Is this another step in the govt pushing docs to become more administrators and

overseers of care, instead of as actually providing the care themselves?

Another example of speeding up the downward slope of physicians.

DrHorvitz

> > No

> > word yet on level of reimbursement and I'm not clear if the counseling

> > can be delegated to an office nurse or nutritionist-type person yet.

>

> Thanks for pointing this out, Carla. The link you provide on the obesity

counseling program indicates that the counseling must be " furnished by a

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

primary care setting " . Those are strictly defined. I really wish I could work

with the nutrition counselor who shares space with me on this, but it doesn't

look that would work.

>

> Haresch

>

[Guest guest]

let's see how much they are going to pay.

maybe 30 dollars for a 50 minute counsel with discussion of blood pressure,

renewals of diabetic meds...

obesity counselling in lieu of 99214...

opens us up to audits if you asked me..

medicare now is looking to 'recoup' payouts that have been up to 2 years prior

....

we are going to be seniors soon... who is going to take care of us with how this

is all panning out?

SIGH...

> > > No

> > > word yet on level of reimbursement and I'm not clear if the counseling

> > > can be delegated to an office nurse or nutritionist-type person yet.

> >

> > Thanks for pointing this out, Carla. The link you provide on the obesity

counseling program indicates that the counseling must be " furnished by a

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

primary care setting " . Those are strictly defined. I really wish I could work

with the nutrition counselor who shares space with me on this, but it doesn't

look that would work.

> >

> > Haresch

> >

>

[Guest guest]

Good fine-print catch. Interesting. Will have to see what the dollars are. In my

situation, I could make the nutrition counselor an employee. I don't know if it

would be worth it unless other payers picked this up and did the same. Hmmmm....

I'm not really looking to do this intensive therapy myself. Food issues are so

involved, I have found that it often takes a special connection with a counselor

and lots of time to figure out how to help someone. The counselor in my office

is successful at that in a way that I don't think I could be.

Haresch

> > No

> > word yet on level of reimbursement and I'm not clear if the counseling

> > can be delegated to an office nurse or nutritionist-type person yet.

>

> Thanks for pointing this out, Carla. The link you provide on the obesity

counseling program indicates that the counseling must be " furnished by a

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

primary care setting " . Those are strictly defined. I really wish I could work

with the nutrition counselor who shares space with me on this, but it doesn't

look that would work.

>

> Haresch

>

[Guest guest]

,I found a bit more - the relationship does not have to be that of a traditional employee/employer:

§410.26 Services

and supplies incident to a physician’s professional services:

Conditions.

(a)

Definitions. For purposes of this section, the following definitions

apply:

(1)

Auxiliary personnel means any individual who is acting under the

supervision of a physician (or other practitioner), regardless of

whether the individual is an employee, leased employee, or

independent contractor of the physician (or other practitioner) or of

the same entity that employs or contracts with the physician (or

other practitioner).But, as pricklyfinger (is that Grace?) commented, with Medicare, the reimbursement may not be very generous and that decreases the allure of contracting it out. Carla To: Sent: Sunday, December 4, 2011 2:26 PM Subject: Re: CMS coverage for Obesity counseling and CVD risk reduction

Good fine-print catch. Interesting. Will have to see what the dollars are. In my situation, I could make the nutrition counselor an employee. I don't know if it would be worth it unless other payers picked this up and did the same. Hmmmm....

I'm not really looking to do this intensive therapy myself. Food issues are so involved, I have found that it often takes a special connection with a counselor and lots of time to figure out how to help someone. The counselor in my office is successful at that in a way that I don't think I could be.

Haresch

> > No

> > word yet on level of reimbursement and I'm not clear if the counseling

> > can be delegated to an office nurse or nutritionist-type person yet.

>

> Thanks for pointing this out, Carla. The link you provide on the obesity counseling program indicates that the counseling must be "furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting". Those are strictly defined. I really wish I could work with the nutrition counselor who shares space with me on this, but it doesn't look that would work.

>

> Haresch

>

[Guest guest]

I think Medicare set a fairly generous reimbursement rate for their annual wellness visits- particularly considering that your employee/auxiliary personnel can complete the visit as incident to. Or, for those beneficiaries who are capable, they can complete your visit forms at home or online before the visit and it takes about 10 minutes to finish the preventive counseling yourself, if all you try to do is meet the CMS requirements and you are organized. Plus, you can tag on E & M codes to that visit when appropriate. If that is not allowed with these visits, I will have no problem making it clear from the beginning that they will need a separate visit for problems.Who knows what they will do with this

behavioral intervention counseling... I would think that it would bankrupt them if everyone who is eligible (30% of the Medicare rolls) took advantage of all the visits.Carla Gibson FNPMissoula, MT To: Sent: Sunday, December 4, 2011 9:49 AM Subject: Re: CMS coverage for

Obesity counseling and CVD risk reduction

let's see how much they are going to pay.

maybe 30 dollars for a 50 minute counsel with discussion of blood pressure, renewals of diabetic meds...

obesity counselling in lieu of 99214...

opens us up to audits if you asked me..

medicare now is looking to 'recoup' payouts that have been up to 2 years prior ...

we are going to be seniors soon... who is going to take care of us with how this is all panning out?

SIGH...

> > > No

> > > word yet on level of reimbursement and I'm not clear if the counseling

> > > can be delegated to an office nurse or nutritionist-type person yet.

> >

> > Thanks for pointing this out, Carla. The link you provide on the obesity counseling program indicates that the counseling must be "furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting". Those are strictly defined. I really wish I could work with the nutrition counselor who shares space with me on this, but it doesn't look that would work.

> >

> > Haresch

> >

>

[Guest guest]

annual wellness visits is different than obesity counseling.

obesity counselling requires leading dx is 278.01

and pays negotiated rate/cutdown of 99213 which is not worth the face to face

time of close to 30-40 minutes depending on what i need to do.

ridiculous...

grace

> > > > No

> > > > word yet on level of reimbursement and I'm not clear if the counseling

> > > > can be delegated to an office nurse or nutritionist-type person yet.

> > >

> > > Thanks for pointing this out, Carla. The link you provide on the obesity

counseling program indicates that the counseling must be " furnished by a

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

primary care setting " . Those are strictly defined. I really wish I could work

with the nutrition counselor who shares space with me on this, but it doesn't

look that would work.

> > >

> > > Haresch

> > >

> >

>