March 14 2012 Overview Current Geriatric Sarcopenia Screening Diagnosis and Treatment Options Medicare Coverage and Reimbursement Objectives ID: 777777
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Slide1
Geriatric Sarcopenia
Draft Timeline for Obtaining Medicare Coverage and Reimbursement for Screening, Diagnosis and Treatment March 14, 2012
Slide2Overview
Current Geriatric Sarcopenia Screening, Diagnosis and Treatment OptionsMedicare Coverage and Reimbursement Objectives
Expand Patient Access to Current Geriatric Sarcopenia Screening, Diagnosis and Treatment Options
Pave the Way for New Therapeutics
Summary Timeline
© 2012, Applied Policy LLC, All Rights Reserved
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Slide3Current Geriatric Sarcopenia Screening, Diagnosis and Treatment Options
Slide4Geriatric Sarcopenia Screening
Elderly patients with observed declines in physical function, strength, or overall health potentially have geriatric sarcopenia© 2012, Applied Policy LLC, All Rights Reserved
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Geriatric
sarcopenia
should be specifically considered in patients who are:
Bedridden
Cannot independently rise from a chair
Who have an unusually slow gait speed
Slide5Geriatric Sarcopenia Diagnosis
A diagnosis of sarcopenia
is consistent with:
a low
functional assessment score; and
an objectively measured
low muscle mass.No specific ICD
Code
ICD-9 728.2 and ICD-10 M62.5
,
“muscle
wasting,
NEC” often does not support payable claims
Functional Assessment
: Patients at risk for
sarcopenia
should undergo a functional assessment, such as the Short Physical Performance Battery (SPPB) or a gait speed test.
© 2012, Applied Policy LLC, All Rights Reserved
5
Objective Muscle Mass Measurement
: Patients who meet the screening criteria should have a body composition assessment using dual energy x-ray absorptiometry (DXA) scan.
Slide6Geriatric Sarcopenia Treatment
Examples of current treatments for
geriatric
sarcopenia
include:
Vitamins and other supplements
Nutrition therapy
Exercise / Training / Physical Therapy
Lifestyle Education / Counseling
Muscle stimulation by device
Drug interventions
©
2012,
Applied Policy LLC, All Rights Reserved
6
Slide7Geriatric Sarcopenia Medicare Coverage and Reimbursement Objectives
Slide8Access Expansion: Current Geriatric Sarcopenia Screening, Diagnosis & Treatment
Work to Expand Geriatric Sarcopenia Screening and Diagnosis
Expand Access to Geriatric Sarcopenia
Screening under Medicare
Create a Geriatric Sarcopenia Diagnosis Code
Establish generally accepted functional assessment
Support the Establishment of Clinical Guidelines for the Diagnosis and Treatment of Geriatric SarcopeniaEliminate Barriers to Non-Pharmaceutical Treatments
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2012,
Applied Policy LLC, All Rights Reserved
8
Slide9Pave the Way for New Therapeutics
Create a Reimbursement Pathway for New Pharmaceutical TreatmentsFor small molecule and self-administered biopharmaceuticals
Establish USP categories and classes suitable for geriatric sarcopenia treatment
Ensure any therapeutic and generic substitution rules are appropriate
Non-self-administered drugs and biopharmaceuticals
Ensure no restrictions on coverage at national and local levels
Support award of unique billing codesSupport CMS approval of HOPD pass-through status
©
2012,
Applied Policy LLC, All Rights Reserved
9
Slide10Summary Timeline: Medicare Coverage and Reimbursement Objectives
Slide11Geriatric Sarcopenia Medicare Reimbursement Timeline
© 2012, Applied Policy LLC, All Rights Reserved
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2012
2013
2014
2015201620172018
Draft
Legislation
Introduction and Congressional Consideration
Enactment
CMS Implementation
Development/Approval of Clinical Guidelines
Modify CDC Health Risk Assessment Guidance
Modify USP Categories and Classes
Petition WHO for ICD-10 Update
Work to Obtain Positive USPSTF Recommendation
Development/Endorsement of Quality Metrics
Drug Pipeline Analysis
Medicare Input to Phase III
Coverage/Reimbursement Issues Based on Testosterone
Support Patient Access and Coverage, Coding & Payment
Slide12Transforming
Intention into Action
(202) 558-5272
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jscott@appliedpolicy.com