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PAs on Front Lines of Obesity Treatment

Posted By Barbara Cortright, PA-C, Wednesday, March 28, 2018

Primary care providers increasingly find themselves taking the leading role in weight loss assessment and treatment, thanks to additional pressures form insurance plans and interest from patients who prefer to start their journey with practitioners they know best.

Numerous studies show that obesity contributes to diabetes, high cholesterol, high blood pressure and mood changes, such as depression and poor self-perception. Thankfully, physician assistants have several tools and approaches that can work for treating obesity.

One approach is to order pertinent labs and a pregnancy test. Once those are analyzed to help confirm the diagnosis and rule out pregnancy, the patient may be referred to at least one consultation with a licensed nutritionist before treatment commences. Exercise will need to be addressed following the guidelines for at least 150 minutes of moderate aerobic exercise each week, about 30 minutes per day for five days each week, according to American Heart Association guidelines.

Frequent follow-up visits are essential. Patients should go no longer than 1 month between visits during this time so that the PA can play a supportive role in their efforts. Weight Watchers is widely available in metropolitan areas and is one source for dietary support and to help shrink portion size.

Pressure from the patient for an initial prescription of phentermine should be diplomatically avoided initially until the patient’s own efforts at diet and exercise can begin to take hold. If this medication is prescribed, safety recommendations include monitoring heart rate and blood pressure throughout the course of treatment because of phentermine's stimulant qualities.

Qsymia has been shown to be the most effective FDA-approved medication for weight loss. It combines phentermine with Topamax (topiramate). Public insurance like Medicaid and Medicare may require a prior authorization for it, but generic forms of the components are available for separate prescription, possibly avoiding the prior authorization process. Dosage of Qsymia ranges from 3.75mg IR/23mg ER of phentermine/topiramte to a 15mg IR/92mg ER combination.

Conversely, patients may prefer a quick fix. If obese patients meet medical criteria and have consulted with a nutritionist, they may request a referral to a bariatric surgeon. However, patients may need to be reminded of the risk of obesity returning if post-operative diet and exercise regimens are not followed.

Regardless of the approach, documentation is key. Any weight changes or wild fluctuations should be noted high in the objective portion of a note. Most records systems offer separate diagnosis codes for obesity, depending on the BMI. Most record systems list the criteria in the drop-down menus, but the corresponding BMI rates for diagnosis codes are generally:

Overweight – BMI 25.0 to 29.9
Obese – BMI 30 to 39.9
Morbid obesity – BMI greater than 40

And remember all that time spent in support and education? PAs can bill by time instead of a standard follow-up encounter. They may ask their billing coordinator for suggestions or visit the American Academy of Family Physicians for more information.

Barbara Cortright, PA-C

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