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The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
The CMS Personalized Preventive Services Pyramid
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The CMS Personalized Preventive Services Pyramid

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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 …

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”.

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  1. “The Medicare Pyramid of Personalized Preventive Servicesand a Case for Annual Wellness Visits to Drive Adoption” George Marmo GM Consulting LLC 1
  2. “The Centers for Medicare & Medicaid Services (CMS)recognizes the crucial role that health care providers play ineducating Medicare beneficiaries about potentially life-saving preventive services and screenings, and in providingthese services.”“While Medicare pays for a variety of preventive benefits,many Medicare beneficiaries do not fully realize that usingpreventive services and screenings can help them livelonger, healthier lives. As a health care professional, youcan help your Medicare patients understand the importanceof disease prevention, early detection, and lifestylemodifications that support a healthier life.” CMS, ICN 907786 July 2012 2
  3.  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 * The Affordable Care Act – A Stronger Medicare Program, 2012 Annual Report 3
  4. By advocating the Initial Preventive Physical Exam(IPPE) and Annual Wellness Visits (AWV) as a firststep, Medicare will greatly increase the adoption ofthe pyramid of Personalized Preventive Services toachieve their goal of “disease prevention, earlydetection, and lifestyle modifications that support ahealthier life”.In particular, the AWV includes Risk Factors whichhelp identify intervention as part of the mandatoryScreening Schedule for the physician andPersonalized Health Advice for the patient. 4
  5. The Medicare Pyramid of Personalized Preventive Services Initial Preventive Physical Exam Initial Annual Wellness Visit Subsequent AWV Cardiovascular Diabetes and Aortic Aneurysm Screening Pap TestSeasonal Influenza Virus Screening Pelvic Exam Pneumococcal Screening Mammography Hepatitis B (HBV) Obesity Alcohol Tobacco Depression 5
  6. Service Description Proc Par Code Fee Initial Preventive Physical Examination Also known as “Welcome to G0402 $181.77 (IPPE) Medicare Preventive Visit” Initial Annual Wellness Visit Initial personalized prevention plan G0438 $188.63 and review of Health Risk Assessment Subsequent Annual Wellness Visit Updated personalized prevention G0439 $125.36 plan and review of Health Risk AssessmentJanuary 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions 6
  7. Service Description Proc Par Code Fee Intensive Behavioral Therapy (IBT) for Face-to-face behavioral G0447 $27.95 Obesity counseling, 15 minutes per visit, 22 visits per year. Screening and Behavior Counseling to Annual alcohol misuse screening, G0442 $20.87 reduce Alcohol Misuse 15 minutes Screening and Behavior Counseling to Brief face-to-face behavioral G0443 $27.95 reduce Alcohol Misuse counseling, 15 minutes, 4 visits per year. Counseling to Prevent Tobacco Use Intermediate smoking and G0436 $15.34 tobacco cessation counseling, 10 minutes, 8 visits per year Counseling to Prevent Tobacco Use Intensive smoking and tobacco G0437 $29.72 cessation counseling, 10 minutes, 8 visits per year Screening for Depression Furnished in primary care setting G0444 $20.87 with staff assisted depression care supportJanuary 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions 7
  8. Service Description Proc Par Code Fee Screening Pelvic Examinations Cervical or vaginal cancer screening, G0101 $42.88 pelvic and clinical breast examination, annual for high risk or 24 months Screening Pap Smear Screening cytopathology, cervical or G0124 $35.35 vaginal, annual for high risk or 24 G0141 $35.35 months Screening Mammography Screening Mammography, digital, G0202 $161.01 annualJanuary 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions 8
  9. Service Description Proc Par Code Fee Cardiovascular Screening Blood Tests Medicare beneficiaries without 80061 tbd apparent signs of 82465 tbd cardiovascular disease 83718 tbd 84478 tbd Ultrasound Screening for Abdominal Medicare beneficiaries with G0389 $128.55 Aortic Aneurysm (AAA) certain risk factors for AAA as a result of an IPPE Diabetes Screening Tests Medicare beneficiaries with 82947 tbd certain risk factors for 82950 tbd diabetes or diagnosed with 82951 tbd pre-diabetes every 5 years Diabetes Self-Management Testing Up to 10 hours of initial G0108 $57.15 trainingJanuary 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions 9
  10. Service Description Proc Par Code Fee Bone Mass Measurements Single Energy X-ray study G0130 $40.00 Colorectal Cancer Screening Flexible Sigmoidoscopy G0104 $166.99 High Risk Colonoscopy G0105 $466.38 Barium Enema (alt to G0104) G0106 $262.55 Barium Enema (alt to G0105) G0120 $262.55 Low Risk Colonoscopy G0121 $466.38 Fecal Occult Blood Test G0328 tbd Prostate Cancer Screening Digital Rectal Exam G0102 $22.94 Prostate Specific Antigen (PSA) G0103 tbd Glaucoma Screening By an Optometrist G0117 $63.45January 2013 Medicare Physician’s Fee Schedule – New Jersey Locality 01, Novitas Solutions 10
  11.  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. 11
  12. George Marmo GM Consulting LLCBusiness Development Manager (973) 524-5048 gmconsultllc@gmail.com 12

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