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Medicare coverage of care planning

Cognitive decline — including Alzheimer's disease and other dementias — can be difficult and time consuming to discuss with patients. Although in-depth care planning is beneficial for all, this type of service has not been covered under Medicare — until now.

The new G0505 Medicare code provides reimbursement for a clinical visit that results in a comprehensive care plan, allowing you to deliver services that can contribute to a higher quality of life for your patients. Clinicians who can be reimbursed under the code include: physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives.

Care planning for individuals with dementia is an ongoing process and a formal update to a care plan should occur at least once per year or when indicated by disease progression.

Who is eligible to receive the services?

All Medicare beneficiaries who are cognitively impaired are eligible to receive the services under the new code. This includes those who have been diagnosed with Alzheimer's, other dementias, or mild cognitive impairment. It also includes those individuals without a clinical diagnosis who, in the judgment of the clinician, are cognitively impaired.

What elements are required?

A cognition-focused exam is comprehensive, and an interview with a family member or caregiver is always desirable and often necessary to obtain an accurate history and description of current issues.

The nine assessment elements of G0505 listed below can be evaluated within the care planning visit or in one or more visits that precede it, using appropriate billing codes (most often an E/M code). Patients with complex medical, behavioral, psychosocial, and/or caregiving needs may require a series of assessment visits, while those with less complex problems may be fully assessed during the care plan visit itself.

Service Elements of Billing Code G0505

Cognition-focused evaluation, including a pertinent history and examination of the patient

Medical decision making of moderate or high complexity (defined by the E/M guidelines)
Document medical decision-making of moderate or high complexity as defined by E/M guidelines

Medication reconciliation and review for high-risk medications, if applicable

Evaluation for neuropsychiatric and behavioral symptoms, including depression and including use of standardized instruments

Evaluation of safety (for example, home safety), including motor vehicle operation, if applicable

Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports and the willingness of caregiver to take on caregiving tasks

Advance care planning and addressing palliative care needs, if applicable and consistent with beneficiary preference

Creation of a care plan, including initial plans to address any neuropsychiatric symptoms and referral to community resources as needed (for example, adult day programs and support groups).

The care plan must be shared with the patient and/or caregiver at the time of initial education and support, and this discussion must be documented in the clinical note for all encounters billed using G0505.

 


Resources to Help You Deliver

The Alzheimer's Association, with the help of an expert task force, has compiled a comprehensive toolkit to help you conduct a visit under the code. The toolkit includes easy access to validated measures, such as the Mini-Cog and Dementia Severity Rating Scale, and newly designed assessment tools:

Medicare's Cognitive Impairment Assessment and Care Planning Code

Medicare's Cognitive Impairment Assessment and Care Planning Code:

The Alzheimer's Association Expert Taskforce recommendations and tools for implementation.

>    Download

Safety Assessment Guide and Checklist

Safety Assessment Guide and Checklist:

Questions to identify safety-related concerns and outline steps to keep the dementia patient safe.

>    Download Checklist

Caregiver Profile Checklist

Caregiver Profile Checklist:

Assess a caregiver's ability and willingness to provide care.

>    Download Checklist

End Of Life Checklist

End-of-Life Checklist:

Screen to identify care preferences and legal needs.

>    Download Checklist

Patient and Caregiver Resources:

Patient and Caregiver Resources:

Links to helpful caregiving, safety and end-of-life resources.

>    Download Resources
Download Toolkit


Alzheimer's Association Expert Task Force

Soo Borson, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA; Memory Disorders Clinic and Dementia Health Services, University of Washington School of Medicine, Seattle, WA

Malaz Boustani, Indiana University Center for Aging Research, Indianapolis, IN; Regenstrief Institute, Inc., Indianapolis, IN; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN

Anna Chodos, Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA; Zuckerberg San Francisco General Hospital, San Francisco, CA

Josh Chodosh, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Geriatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

Jatin Dave, New England Quality Care Alliance (NEQCA), Boston, MA

Lisa Gwyther, Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC; Joseph and Kathleen Bryan Alzheimer's Disease Research Center (Bryan ADRC), Duke University School of Medicine, Durham, NC

Monica Parker, Division of Geriatrics and Gerontology, School of Medicine, Emory University, Atlanta, GA; Emory Alzheimer's Disease Research Center, School of Medicine, Emory University, Atlanta, GA

Susan Reed, Kelsey-Seybold Clinic, Houston, TX

David Rueben, Division of Geriatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA

Stephen Stabile, PrimeCare Community Health, Chicago, IL

Matthew Baumgart, Alzheimer's Association, Chicago, IL

Beth Kallmyer, Alzheimer's Association, Chicago, IL

Joanne Pike, Alzheimer's Association, Chicago, IL

Bill Thies, Alzheimer's Association, Chicago, IL


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