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© Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Draft Timeline for Obtaining Medicare Coverage and Reimbursement for.

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Presentation on theme: "© Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Draft Timeline for Obtaining Medicare Coverage and Reimbursement for."— Presentation transcript:

1 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Draft Timeline for Obtaining Medicare Coverage and Reimbursement for Screening, Diagnosis and Treatment March 14, 2012

2 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Overview Current Geriatric Sarcopenia Screening, Diagnosis and Treatment Options Medicare 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 Reserved2

3 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Current Geriatric Sarcopenia Screening, Diagnosis and Treatment Options

4 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Screening Elderly patients with observed declines in physical function, strength, or overall health potentially have geriatric sarcopenia © 2012, Applied Policy LLC, All Rights Reserved4 Geriatric sarcopenia should be specifically considered in patients who are:  Bedridden  Cannot independently rise from a chair  Who have an unusually slow gait speed

5 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric 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 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 Reserved5 Objective Muscle Mass Measurement: Patients who meet the screening criteria should have a body composition assessment using dual energy x-ray absorptiometry (DXA) scan.

6 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric 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 Reserved6

7 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Medicare Coverage and Reimbursement Objectives

8 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Access 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 Sarcopenia Eliminate Barriers to Non-Pharmaceutical Treatments © 2012, Applied Policy LLC, All Rights Reserved8

9 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Pave the Way for New Therapeutics Create a Reimbursement Pathway for New Pharmaceutical Treatments  For 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 codes Support CMS approval of HOPD pass-through status © 2012, Applied Policy LLC, All Rights Reserved9

10 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Summary Timeline: Medicare Coverage and Reimbursement Objectives

11 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Medicare Reimbursement Timeline © 2012, Applied Policy LLC, All Rights Reserved11 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

12 © Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Transforming Intention into Action (202) |


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