the cms personalized preventive services pyramid
Post on 25-Jan-2015
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“The Medicare Pyramid of
Personalized Preventive Services
and a Case for Annual Wellness Visits
to Drive Adoption”
George Marmo
GM Consulting LLC
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“The Centers for Medicare & Medicaid Services (CMS) recognizes the crucial role that health care providers play in educating Medicare beneficiaries about potentially life-saving preventive services and screenings, and in providing these services.”
“While Medicare pays for a variety of preventive benefits, many Medicare beneficiaries do not fully realize that using preventive services and screenings can help them live longer, healthier lives. As a health care professional, you can help your Medicare patients understand the importance of disease prevention, early detection, and lifestyle modifications that support a healthier life.”
CMS, ICN 907786 July 2012
Although most of the 35.5 million Original Medicare (Part B) enrollees used one or more free Preventive Service in 2012, less than 9% utilize the Annual Wellness Visit or AWV
Only Cardiovascular Disease Screening Blood Tests and Seasonal Influenza Virus Vaccination were utilized by more than half the enrollees
Of the 10 most populated states, half were below the national average of 9% in AWV usage with a range between 6–12%
New Jersey has the 10th largest Medicare population and is slightly above the national average utilizing AWV
3* The Affordable Care Act – A Stronger Medicare Program, 2012 Annual Report
By advocating the Initial Preventive Physical Exam (IPPE) and Annual Wellness Visits (AWV) as a first step, Medicare will greatly increase the adoption of the pyramid of Personalized Preventive Services to achieve their goal of “disease prevention, early detection, and lifestyle modifications that support a healthier life”.
In particular, the AWV includes Risk Factors which help identify intervention as part of the mandatory Screening Schedule for the physician and Personalized Health Advice for the patient.
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The Medicare Pyramid of Personalized Preventive Services
Seasonal Influenza VirusPneumococcal
Hepatitis B (HBV)
CardiovascularDiabetes and
Aortic Aneurysm
Screening Pap TestScreening Pelvic ExamScreening Mammography
Initial Preventive Physical ExamInitial Annual Wellness VisitSubsequent AWV
ObesityAlcohol
TobaccoDepression
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Service Description ProcCode
Par Fee
Initial Preventive Physical Examination (IPPE)
Also known as “Welcome to Medicare Preventive Visit”
G0402 $181.77
Initial Annual Wellness Visit Initial personalized prevention plan and review of Health Risk Assessment
G0438 $188.63
Subsequent Annual Wellness Visit Updated personalized prevention plan and review of Health Risk Assessment
G0439 $125.36
January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions
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Service Description ProcCode
Par Fee
Intensive Behavioral Therapy (IBT) for Obesity
Face-to-face behavioral counseling, 15 minutes per visit, 22 visits per year.
G0447 $27.95
Screening and Behavior Counseling to reduce Alcohol Misuse
Annual alcohol misuse screening, 15 minutes
G0442 $20.87
Screening and Behavior Counseling to reduce Alcohol Misuse
Brief face-to-face behavioral counseling, 15 minutes, 4 visits per year.
G0443 $27.95
Counseling to Prevent Tobacco Use Intermediate smoking and tobacco cessation counseling, 10 minutes, 8 visits per year
G0436 $15.34
Counseling to Prevent Tobacco Use Intensive smoking and tobacco cessation counseling, 10 minutes, 8 visits per year
G0437 $29.72
Screening for Depression Furnished in primary care setting with staff assisted depression care support
G0444 $20.87
January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions
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Service Description ProcCode
Par Fee
Screening Pelvic Examinations
Cervical or vaginal cancer screening, pelvic and clinical breast examination, annual for high risk or 24 months
G0101 $42.88
Screening Pap Smear Screening cytopathology, cervical or vaginal, annual for high risk or 24 months
G0124G0141
$35.35$35.35
Screening Mammography Screening Mammography, digital, annual
G0202 $161.01
January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions
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Service Description ProcCode
Par Fee
Cardiovascular Screening Blood Tests
Medicare beneficiaries without apparent signs of cardiovascular disease
80061824658371884478
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Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
Medicare beneficiaries with certain risk factors for AAA as a result of an IPPE
G0389 $128.55
Diabetes Screening Tests Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes every 5 years
829478295082951
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Diabetes Self-Management Testing
Up to 10 hours of initial training
G0108 $57.15
January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions
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Service Description ProcCode
Par Fee
Bone Mass Measurements Single Energy X-ray study G0130 $40.00
Colorectal Cancer Screening Flexible SigmoidoscopyHigh Risk ColonoscopyBarium Enema (alt to G0104)Barium Enema (alt to G0105)Low Risk ColonoscopyFecal Occult Blood Test
G0104G0105G0106G0120G0121G0328
$166.99$466.38$262.55$262.55$466.38
tbd
Prostate Cancer Screening Digital Rectal ExamProstate Specific Antigen (PSA)
G0102G0103
$22.94tbd
Glaucoma Screening By an Optometrist G0117 $63.45
January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions
Awareness about Annual Wellness Visits must be driven from top down and bottom up. Medicare has provided incentives but needs to enhance their current communications to better educate the beneficiary as well as the physician.
State and local governments have a vested interest in reducing health care costs and should implement metrics tied to results to earn program grants similar to CMS incentives for EHR adoption.
State level Mayor organizations can foster participation and issue policy to incorporate action at the local level. As part of the New Jersey Health Care Quality Initiative, Mayor Wellness Campaigns are emerging as a vehicle to convert policy into action.
For many of these Preventive Services, copayment and deductibles have been waived thereby eliminating barriers to the consumer. We all just have to meet in the middle.
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George MarmoGM Consulting LLC
Business Development Manager
(973) 524-5048
gmconsultllc@gmail.com
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