Medicare coverage of - reduce alcohol, smoking cessation, adult immunization

Screening and behavioral counseling in primary care to reduce alcohol misuse

The US Preventive Services Task Force (USPSTF) gives screening and behavioral counseling interventions in primary care to reduce alcohol misuse a B rating, and we urge CMS to cover these services as part of the annual wellness visit/personalized prevention plan. The USPSTF states:

"Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up. Multi-contact interventions for patients ranging widely in age (12-75 years) are shown to reduce mean alcohol consumption by 3-9 drinks per week, with effects lasting up to 6-12 months after the intervention."
Existing CPT Codes for this intervention fully describe these recommended actions, and we urge CMS to include these codes as a covered preventive care service in the final rule.

Smoking Cessation

The RUC has already developed CPT codes for smoking cessation, yet CMS is developing slightly different coding through the national coverage determination process (NCD). We urge CMS to adopt the existing CPT Codes for smoking cessation and cover these services as part of the annual wellness visit/personalized prevention plan.

Recommended Adult Immunizations

When the USPSTF ceased making recommendations with regard to vaccines after CY 1996, it demonstrated its support of the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations by including them in the USPSTF dissemination materials. The AMA urges CMS to adopt the ACIP-recommended adult immunization schedule for adults 65 years and older. This would include, in addition to influenza, pneumococcal and hepatitis B vaccines, the vaccines for Herpes Zoster and Tetanus (Td).

Additionally, as supported by a recent survey published in the Annals of Internal Medicine (Hurley et al, May 4, 2010 vol. 152 no. 9 555-560), payment for vaccines via Part D Medicare is a barrier to physicians administering the vaccine. With the coverage for shingles vaccine (reimbursed via Medicare Part D) at an unacceptably low two percent rate, the AMA urges that all vaccines recommended by the ACIP and covered by Medicare be reimbursed via Medicare Part B. This would bring all vaccines in line with the influenza, pneumococcal and hepatitis B vaccines, which are paid under Medicare Part B.
Assessment of individual functional ability and level of safety should include screening for visual acuity

The AMA applauds inclusion of functional status screening in the first annual wellness visit. However, we are concerned that CMS includes screening only for hearing impairment and not for visual impairment. While the USPSTF has removed visual acuity screening from a B to an I rating because of the lack of scientific research in this area, visual acuity is an important part of multi-factorial fall risk assessment and correction of visual problems is essential in fall prevention programs. The 2009 Guideline for the Prevention of Falls in Older Persons, a joint endeavor of the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons, provides a thorough review of the evidence and recommends that physicians complete a multi-factorial fall risk assessment including: (i) history of falls; (ii) medications; (iii) gait, balance and mobility; (iv) visual acuity; (v) other neurological impairments; (vi) muscle strength; (vii) heart rate and rhythm; (viii) postural hypotension; (ix) feet and footware; and (x) environmental hazards. Clearly, the scientific evidence supports the recommendation to screen for and treat visual impairments, and we therefore urge CMS to include visual acuity services in the annual wellness visit.

Health Risk Assessment

The ACA requires that a health risk assessment (HRA) be included in the new annual wellness visit benefit January 1, 2011. CMS acknowledges, however that the HRA guidelines (with standards for interactive telephonic and web-based HRAs) and the model HRA tool also required by the ACA are not yet available. CMS, therefore, has not included requirements related to the HRA in the proposed rule. The AMA urges CMS to continue to develop the HRA guidelines, in consultation with the AMA and other relevant stakeholders representing physicians. These HRA program should also be pilot-tested before being widely imposed to determine such critical factors as the effectiveness of the guidelines and the administrative burden imposed on the physicians.