business of pediatrics

How Nutrition Services Can Improve Care and Boost Revenue in Your Pediatric Practice

Childhood and teen obesity rates are at epidemic levels in the United States.

According to the Centers for Disease Control (CDC), 1 in 6 kids struggle with obesity. That translates to 17% of all 2-19 year olds, or 12.7 million youth. Here's how that breaks down:

  • 8.9% are 2-5 year-olds
  • 17.5% are 6-11 year-olds
  • 20.5% are 12-19 year-olds

Obesity rates fluctuate between different populations, and tend to be highest in low-income communities. The CDC's research indicates the following:

  • The prevalence of obesity was higher among Hispanics (21.9%) and non-Hispanic blacks (19.5%) than among non-Hispanic whites (14.7%).
  • The prevalence of obesity was lower in non-Hispanic Asian youth (8.6%) than in youth who were non-Hispanic white, non-Hispanic black, or Hispanic.
  • The prevalence of obesity was 8.9% among 2- to 5-year-olds compared with 17.5% of 6- to 11-year-olds and 20.5% of 12- to 19-year-olds. Childhood obesity is also more common among certain populations.

In children and teens, Body Mass Index (BMI) determines obesity, and it is age and sex-specific. The CDC says,

BMI is interpreted differently for children and teens, even though it is calculated using the same formula as adult BMI. Children and teen’s BMI need to be age and sex-specific because the amount of body fat changes with age and the amount of body fat differs between girls and boys. The CDC BMI-for-age growth charts take into account these differences and visually show BMI as a percentile ranking.

Child and Teen BMI Calculator is an important tool to use when assessing whether or not a patient is obese. For kids and teens, obesity is defined as being greater than or equal to the 95th percentile for BMI. Overweight is determined to be greater than or equal to the 85th percentile, but less than or equal to the 95th percentile for BMI.

There are various causes of childhood obesity including:

  • Behavior
    • consuming food and beverages with high calories and low nutrients
    • lack of adequate physical activity or exercise
    • increased sedentary lifestyle
  • Environment
    • poor nutrition at school or day care

Child and teen obesity has health consequences that can be felt both immediately and in the future. Things that impact kids right away include:

  • high blood pressure and cholesterol
  • increased risk for diabetes
  • increase in breathing problems (e.g., asthma)
  • joint problems and musculoskeletal pain
  • anxiety and depression
  • low self-esteem
  • social issues (e.g., being bullied)

For obese children and teens who remain overweight into adulthood, there is an increased risk for heart disease, diabetes, and cancer.

What Can Pediatricians Do to Help Stop Childhood Obesity?

According to a Medscape article, as of 2014, only 1/5th of doctors were providing ancillary services. Within that, only 18% of pediatricians had recently started. As insurance payment rates continue to decline, adding in-house nutrition services can be a good way to boost revenue. Other reasons to add nutrition services to your practice include:

  • makes it easy for families – they can access the service right there instead of going to another location
  • it increases the quality of the care you are providing for your patients; dieticians typically spend an hour with kids, versus the quick check-in that may happen during a well or sick visit
  • offering more services in-house makes you more competitive

Why Add Nutrition Services to Pediatric Practices?

At PCC's annual Users' Conference, our guest speaker Leslie Langevin, RD of Whole Health Nutrition in Winooski, VT, gave a presentation that answered many of the questions surrounding this topic.The following information is excerpted from her class.

In addition to obesity, there are many conditions that warrant a visit with a Registered Dietician. Examples include:

  • Overweight/Underweight
  • Irritable Bowel Syndrome/Irritable Bowel Disease
  • Eating Disorders/Picky Eating
  • Diabetes Type 1 and Type 2
  • Weight loss due to ADHD medication

Topics covered in a session might include:

  • creating an individual, personalized nutrition plan
  • meal planning
  • goal setting
  • nutrition education
  • how to destress food and make it fun
  • learn about mindful eating

What About Billing?

Many insurance plans provide coverage for healthy eating, called Dietary Surveillance and Counseling. Policies vary by state and plan, but often allow for 3 nutrition sessions per year with no referral necessary. When sessions are not preventive in nature and are related to an eating disorder, some insurance plans grant unlimited sessions with prior approval. Medicaid varies by state as well, and in some states it provides unlimited nutrition sessions per year.

Nutritional counseling primarily takes places as:

  1. Individual Sessions
  2. Group Sessions
  3. Classes

Individual Nutritional Counseling

When patients have an individual session with a nutritionist at your office, the sessions are billed out just like any other medical appointment. And as with other medical appointments, they are subject to any "specialist" copays/coinsurance/deductibles associated with the patient's insurance plan. Nutrition billing is separate from well visit billing, so billing for these services does not impact well visits that occurred on the same day. Visits are usually an hour in length, and are billed with the following CPT codes:

  •  97802: Medical Nutrition Therapy (MNT); initial assessment and intervention, individual, face-to-face with the patient. Each unit is 15 minutes. Nutrition services providers typically bill 4 units to comprise a 60 minute session.
  • 97803: Medical Nutrition Therapy (MNT); re-assessment and intervention, individual, face-to-face with the patient. Each unit is 15 minutes. Nutrition services providers typically bill 4 units to comprise a 60 minute session, or sometimes 2 units for a 30 minute session if only a quick follow-up is needed.

Group Sessions, a.k.a. Shared Medical Appointment (SMA)

Another option for providing access to nutrition services, is to provide group nutritional counseling sessions for patients. These 'shared medical appointments' are typically 90 minutes, and there is a requirement that that provider needs to give 15 minutes of individual nutritional counseling within the group setting. Group appointments can potentially involve multiple types of providers, offering a "one stop shopping" experience for patients. For example, a SMA could involve 10 patients, along with a pediatrician, nurse practitioner, and dietician. Patients would have short individual counseling with each in the first half of the session, with group activites/education comprising the remainder of the session. These types of appointments can work well when there is a group of patients who would all benefit from the same type of focus in an appointment, e.g., a focus on patients with eating disorders, or on patients looking for advice on sports nutrition. Group sessions can be billed with the following:

  • 97804: This is the CPT code to use for Group Sessions. Sessions must be 2 or more people each. Each unit is 30 minutes.

Nutrition Classes

A third way to provide nutrition education in pediatric settings is to have a dietician provide classes. They can be geared toward just kids, or kids and parents or caregivers. While classes can't be billed through insurance, they can still be a source of revenue by having patients self-pay. Sometimes grants are available. For example, funding is sometimes given to help foster the community medical home model. This model allows patients to access complete care in one facility. Practices will get grant money to hire providers of nutrition services, mental health services, and the like. If available, the cost of classes can be paid for this way, making them available to patients at no cost. Classes can take place during business hours if your practice has a separate community or event space, or they can run after hours in the office. Benefits of nutrition classes include:

  • Fostering community and building support for patients
  • Learning new techniques
  • Less picky eating as kids are more likely to try eating things that they made
  • Practice activities together, such as mindful eating

Practices can offer several nutrition classes that focus on specific themes. For example:

  • Weight loss
  • Meal planning for families and teens
  • Picky eating
  • Sports nutrition

What to Look for When Hiring a Dietician for Your Practice

Look for someone who will provide a full assessment and dietary analysis for your patients. It's good to find someone who will involve and work with parents, unless the patient is older and wants to work alone. This person will also work to create full meal plans and goals for your patients. Most importantly, Leslie suggests finding someone who is skilled in Motivational Interviewing (MI), a technique she finds works well with patients. With this approach, dieticians focus on helping kids create goals, they discuss 'healthy eating' rather than weight, and they don't use language that instills any sense of shame around eating or weight. With MI, the practitioner facilitates the patient coming up with the goal on their own. This creates greater adherence to the plan, since patients own it on a more personal level.

How Should You Set Up Nutrition Appointments in Your Pediatric Practice?

There are a variety of ways to set this up - you can see what works best for your practice. Your practice's front office staff will usually handle the scheduling. With your staff making the appointments, it's easy for patients to set up an appointment while they are already there seeing the pediatrician. And ease of scheduling means greater follow through for patients. Appointments are most often an hour, but if there are patients who only require quick follow-ups, then you could schedule a series of 30 minute sessions.

In terms of billing, some dieticians will do their own billing. Other times, your practice does the billing for them and takes a percentage of the insurance payment. Although you can hire them, most dieticians work as independent contractors who will pay your practice rent. That said, they should carry their own professional liability insurance so that they are not on your practice's insurance.

After-school hours tend to work well for nutrition appointments. If your office offers evening or weekend hours, that is also a good option. Alternatively, the dietician could use the office during off hours. Your office is a fixed cost. You pay for it whether it is in use or not. Renting space to a provider during off hours is a great way to offset those fixed costs.

While there are several good reasons to add nutrition services to your practice, the most compelling is that is vastly increases the quality and convenience of care for your patients. Additionally, it can be a good source of additional revenue and will make your practice stand out amongst the competition.

Additional Resources

Whole Health Nutrition

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Courtney Edelson

For several years, Courtney Edelson was the Marketing Content Manager at PCC. She wrote for the PCC Blog, and created additional content to keep pediatricians up to date on important healthcare industry news and trends. In addition to being a lifelong writer, Courtney brought nearly a decade of healthcare practice management experience to her work.