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:
Obesity rates fluctuate between different populations, and tend to be highest in low-income communities. The CDC's research indicates the following:
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.
A 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:
Child and teen obesity has health consequences that can be felt both immediately and in the future. Things that impact kids right away include:
For obese children and teens who remain overweight into adulthood, there is an increased risk for heart disease, diabetes, and cancer.
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:
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:
Topics covered in a session might include:
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:
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:
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:
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:
Practices can offer several nutrition classes that focus on specific themes. For example:
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.
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.
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