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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 Screening, Diagnosis and Treatment March 14, 2012
© 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
© Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Current Geriatric Sarcopenia Screening, Diagnosis and Treatment Options
© 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
© 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-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 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.
© 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
© Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Geriatric Sarcopenia Medicare Coverage and Reimbursement Objectives
© 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
© 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
© Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Summary Timeline: Medicare Coverage and Reimbursement Objectives
© 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
© Copyright 2010 Applied Policy, L.L.C., All Rights Reserved. Transforming Intention into Action (202) 558-5272 | firstname.lastname@example.org
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