Medicare Reimburses for Cognitive Care Planning Services
More than 5 million individuals in the United States are currently affected by Alzheimer’s disease or other related dementias, with more than 510,000 of those patients living in Michigan.[i] Across this country the care and support for these 5 million individuals are borne by more than 15 million family caregivers who, it is estimated, provide unpaid care equivalent to 18.2 billion hours of care at a value of more than 230 billion dollars per year.[ii] To ensure coordination of care for patients diagnosed with various dementias and to limit caregiver burnout, it is imperative that clinicians, patients, and caregivers discuss the needs of patients and caregivers, including all available resources to support care objectives.
When clinicians provide services aimed at improving the detection, diagnosis, care planning and coordination of care for individuals with Alzheimer’s disease and related dementias, patient care is improved and valuable resources are provided to the patients and their caregivers. In support of these goals, Medicare now provides reimbursement to healthcare providers who are eligible to report and submit claims for evaluation and management services (e.g. physicians, nurse practitioners, clinical nurse specialists, and physician assistants).
Who Could Benefit from Cognitive Care Planning Services? Patients who meet the following criteria could benefit from reimbursable cognitive care planning services:
- Individuals with first time cognitive impairment who are in need of care plans to establish diagnoses; OR
- Individuals with existing diagnoses of neurodegenerative or other central nervous system or general medical conditions causing cognitive impairment; AND
- Individuals at risk for further cognitive, functional, and/or neurobehavioral deterioration, for any reason, including progression of the disease; onset or worsening of another medical or surgical problem; acute hospitalization or emergency care; changes in available level of care and support; or any other circumstances likely to adversely affect the patients’ health and wellbeing.
Requirements of G0505 Reimbursement. In order to qualify for reimbursement under HCPCS code G0505[iii], clinicians must conduct a multidimensional assessment that includes cognition, function, and safety issues; evaluation of neuropsychiatric and behavioral symptoms; review and reconciliation of medications; and assessment of the needs of the patient’s caregiver. Clinicians conducting a cognition-focused evaluation should include discussions with a family members and/or caregivers, in order to obtain an accurate and complete history and description of current medical and non-medical issues. The cognition-focused exam should include the following key elements:
- Documentation of medical decision-making of moderate or high complexity;
- Assessment of activities of daily living functioning which addresses the patient’s decision-making capacity and need for assistance from others (e.g. feeding, hydration, hygiene, and safety), the patient’s recognition of his/her own cognitive impairment, patient’s ability to communicate with healthcare providers, and his/her ability to understand medical advice given;
- Staging the severity of cognitive impairment;
- Reviewing medication use, including high risk prescriptions and over the counter medications;
- Assessment of neuropsychiatric and behavioral symptoms, including depression;
- Evaluation of safety concerns (e.g. medication, home hazards, access to weapons, ability to drive an automobile, and ability to stay alone);
- Identification of the caregiver(s) and assessment of the caregiver’s knowledge, needs to care for the patient, social supports, and the caregiver’s ability and willingness to continue caregiving tasks;
- Discussions regarding advance care planning and palliative care needs; and
- Creation of a written care plan, including an initial plan to address neuropsychiatric symptoms, referrals to community resources for the patient and caregiver(s), and any additional medical evaluation and diagnostic testing, if needed.
- The clinician must document the results of the evaluation and assessment in a written care plan which is provided to the patient/caregiver(s) and accompanied by relevant education and support resources. The Alzheimer’s Association, in addition to a 24 hour help line, has many resources for clinicians and caregivers.[iv]
- All discussions and encounters billed using HCPCS code G0505 along with the written care plan must be documented as part of the patient’s medical record.
For additional information related to cognitive impairment assessment and care planning, visit the Alzheimer’s Association website.[v] For specific reimbursement and legal questions contact Donna J. Craig, RN, JD with The Health Law Center, PLC., at email@example.com.
Disclaimer and Disclosure – This article was prepared as a general summary of the 2017 Medicare Physician Fee Schedule Final Rule which addresses reimbursement for cognitive impairment assessment and care planning, and is not intended to take the place of legal advice and counsel regarding any particular circumstance or factual scenario. Ms. Craig is currently the Vice Chair of the Michigan Great Lakes Chapter of the Alzheimer’s Association.
[i] “2017 Alzheimer’s Disease Fact and Figures”, Alzheimer’s Association, http://www.alz.org/facts/overview.asp, July 2017
[iii] “Summary of Policies in the Calendar Year (CY) 2017 Medicare Physician Fee Schedule Final Rule, MLN Matters® Number: MM9844”, Department of Health & Human Services, Centers for Medicare & Medicaid Services, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9844.pdf , January 3, 2017
[iv] Alzheimer’s Association, Michigan Great Lakes Chapter, http://www.alz.org/gmc/, July 2017
[v] “Medicare’s Cognitive Impairment Assessment and Care Planning Code: Alzheimer’s Association Expert Task Force Recommendation s and Tools for Implementation”, Alzheimer’s Association, http://www.alz.org/careplanning/downloads/cms-consensus.pdf, July 2017.