Obesity is an epidemic that causes 1 in every 5 deaths in America and costs approximately 190.2 billion annually in healthcare costs.
In our pilot, it was sometimes my responsibility to meet with patients before they met with the wellness nurse. Often, during this interaction, patients would open up and share issues they were concerned about. One patient in particular came in complaining that she just didn’t feel like she used to. She had developed restless leg syndrome, often had unexplained pain and she was sure her memory was getting worse. As we went through our interview, I learned that she had gained over 50 lbs since she retired only a couple of years before. I asked what she thought was behind that and she said, “Well, all I have to do all day is eat and watch TV.” After I got through with our interview, I said, “You know I’m not an expert but I just read a study that said that obesity and lack of activity can lead to all the issues you’ve brought up. Would you be willing to talk to our Nurse Practitioner who does weight loss counseling and see if that doesn’t alleviate some of these issues?” I was pleasantly surprised the patient seemed happy about the prospect and agreed to visit with the NP about these issues. Over the following year, I saw this patient come in several times for her weight loss visits. Her appearance made it obvious the counseling sessions were being successful. The next year, when this patient returned for her subsequent annual wellness visit, we discussed her weight loss success and I asked if the program had helped her with the other issues she was having. She shook her head affirmatively and said that the “NP had really been able to help her.”
As we prepare for the new year, it seems apropos to consider weight loss counseling in primary care. I know most of us don’t put much stock into New Years resolutions, but don’t be so quick to dismiss them. A study by JC Norcross found that nineteen percent of people who make a New Year’s Resolution successfully keep it.
So, what does that have to do with your practice? In his study, Norcross states that people who commit to losing weight as a New Year’s Resolution are successful because they have the social supports (due to the time of year) to do so. If we can develop the same support system throughout the rest of the year, the research seems to support that a weight loss program could be successful whenever a patient is ready, willing and able to begin. Luckily, Medicare has given providers the ability to create this support structure for their patients through the funding of its Intensive Behavioral Therapy For Obesity (IBTO) program . Patients don’t have to wait until January to start a program and get the support needed to succeed.
Scientific Review and Recommendations:
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) reports that one third of all Americans are considered obese. They also report Overweight and obesity are risk factors for many health problems such as type 2 diabetes, high blood pressure, joint problems, and gallstones, among other conditions.
Obesity has been described as an epidemic in America due to the health concerns related to it. These concerns for obesity are what led the United States Preventive Service Task Force (USPSTF) to recommended behavioral counseling with patients who had a Body Mass Index over 30. That recommendation is the primary requirement of Medicare’s reimbursement for what they refer to as Intensive Behavioral Therapy for Obesity (IBTO.)
IBTO Requirements and Frequency of Visits:
Medicare beneficiaries with obesity, defined as Body Mass Index (BMI) equal to or greater than 30, 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 in a primary care setting, are eligible for up to 20 IBTO visits annually:
- One face-to-face visit every week for the first month;
- One face-to-face visit every other week for months 2-6; and
- One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement during the first 6 months.**
**Note, the requirement for Months 7-12 state the patient must have met a weight loss of 3kg or 6.6 lbs to qualify for ongoing treatment. That is roughly 1.1 pound per month cumulative.
IBTO is an area where practices may have the greatest potential for increasing patient outcomes. However, it does require a bit of attention to logistics if it is to be done successfully.
Logistically, we recommend you develop a program that includes wellness nurses or dietitians. The nurse/dietitian needs to be able to support the 5 “A’s” of wellness (required by Medicare.)
Note: For Fee for Service (MIPS or APM) providers, the visit reimbursement is rather low. For success using IBTO in those settings, these practices will need to plan very carefully to make the program as efficient as possible.
USPSTF 5 As
Unlike the Medicare Annual Wellness Visit, the provider is required to see the patient after the dietitian or wellness nurse. Providers should use this time to ensure all the USPSTF’s 5 “A’s” for behavioral counseling are covered. The following is the guidelines put out by the USPSTF regarding how the 5 As should be conducted:
- Assess: Ask about/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.
Group IBTO Sessions:
If you wish to utilize a group environment, you can use code G0473. Note the reimbursement for group counseling is approximately half of that of G0447. Using a variation of G0447 and G0473 may be a good idea as a group dynamic has proven to be effective in promoting weight loss.
To efficiently implement your program we recommend you develop a reliable documentation process. The following outlines some of the documentation recommended:
- The practice should create a template to ensure all 5 A’s are documented upon the completion of each IBTO visit.
- Documentation should be recorded demonstrating the patient’s level of motivation upon beginning the visits.
- The patient’s plan of action should be saved in their chart to ensure the provider can review it periodically and to determine if patient is following through with their plan.
- If a patient is receiving Chronic Care Management services, the IBTO Plan of Action should be integrated into their care plan and monitored by the CCM nurse.
- Any health literacy covered with the patient should be included in the documentation as well.
- The patient’s progress should be documented with a strong emphasis on month 6 (noting whether or not the patient qualifies for further treatment.)
Federally Qualified Health Centers:
Federally Qualified Health Centers have unique opportunities for providing this visit. Because FQHCs are reimbursed upon a flat PPS rate and the IBTO is an approved PPS code, this makes it more practical for FQHCs to offer this service to their Medicare patients.
Note: FQHCs also have the restriction that prevents them from being able to implement more than one visit per day with a patient. This means the IBTO must be a stand alone visit. FQHCs are prohibited from billing for G0437 (group sessions.)
Reimbursement for a strong IBTO program in a FQHC can be significant and even exceed that of the Annual Wellness Visit (which reimburses approximately 33 percent more than a normal visit.)
Reimbursement Comparison Table:
|Type of Practice||Number of Patients||Average Reimbursement||Reimbursement||Number of Visits||Total Reimbursement|
|Fee for Service Practice||100||$25||$2500||20||$50,000|
Sample of Quality Measures Met:
|Adult Weight Screening and Follow-up||X||X||X||X||X||X||X||X|
Regardless of what type of primary care provider you are or how many Medicare patients you see, incorporating Medicare’s Intensive Behavioral Therapy for Obesity can make a significant impact on the health of your patient population. The overall goal of your wellness program should be to decrease preventable diseases. Incorporating IBTO to find and reduce the expected 30 percent of your patient load who qualify as obese can make huge inroads in preventing disease and helping your patients increase their quality of life.
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