In 2020, more than 7 million Americans aged 65 or older were living with dementia, according to expert estimates. If current demographic and health trends continue, more than 9 million Americans could have dementia by 2030 and nearly 12 million by 2040.
The Centers for Medicare & Medicaid Services (CMS) has been ramping up its coverage of cognitive care over the years in response to rising rates of Alzheimer's disease, dementia, and related conditions, as well as the growing recognition of the importance of early diagnosis and care planning.
Before 2017, Medicare covered cognitive-related services, such as evaluation and management visits. However, there was no dedicated benefit for comprehensive cognitive care. Providers had to address memory concerns during regular office visits, which were often time-limited and not appropriate for in-depth care planning.
As of 2018, CPT code 99483 replaced G0505, providing coverage for Cognitive Assessment and Care Planning (CACP) services. This encourages providers to screen and manage cognitive issues more proactively.
Additionally, CMS has taken steps in recent years to enhance cognitive care for patients, including:
Here, we focus on four of these services that present reimbursable opportunities. They can support patients living with cognitive impairment, such as Alzheimer’s disease or other dementias, and their family caregivers.
Research indicates that dementia rates increase exponentially with age, doubling every five years between the ages of 65 and 90. One in 10 people aged 65–84 and more than 30% of adults 85 and over are affected. Other research estimates that 50% of people living with dementia have not received a clinical diagnosis.
To help diagnose and treat cognitive impairment earlier, and proactively manage patient symptoms and disease trajectory more holistically, CMS reimburses the following four services. These enable providers to support their growing patient population diagnosed with dementia, whether currently or in the future.
Equipped with the right technology, workflows, and guidance, care teams can bill for valuable services that enhance patient outcomes and quality of life.
The Annual Wellness Visit (AWV) is a yearly appointment focused on prevention and personalized health management. Designed to help Medicare beneficiaries stay healthy, it requires a customized prevention plan based on their individual needs and risk factors. The AWV aids in identifying potential health issues early.
No matter the type of AWV—Initial Preventive Physical Exam (IPPE), Initial Annual Wellness Visit (IAWV), or subsequent AWVs—a cognitive assessment, such as a Mini-Cog, is a required element. However, it's not a formal, comprehensive test, but rather a general check for potential cognitive impairment. This can be done through direct observation, gathering information from family and caregivers, or a brief cognitive test.
If cognitive impairment is found during an AWV or other routine visit, the physician may perform a more detailed cognitive assessment and develop a care plan during a separate visit.
As of January 2018, CPT Code 99483 replaced G0505 for the Cognitive Assessment and Care Plan (CACP). This code reimburses any clinician eligible to report evaluation and management (E/M) services, including:
All cognitively impaired patients are eligible to receive CACP services, including those diagnosed with Alzheimer’s, other dementias, or mild cognitive impairment. However, it also includes those individuals without a clinical diagnosis who the clinician deems cognitively impaired.
CACP is implemented most commonly for these diagnoses, including:
The cognitive assessment can span one or more appointments, but must include a detailed medical history and a comprehensive patient examination. Additionally, an independent historian, who could be a parent, spouse, guardian, or someone who knows the patient well, must be present for assessments and corresponding care planning.
The role of an independent historian is to provide the patient’s history when they are unable to offer a complete or reliable medical history.
Conducted no more than once every 180 days, the CACP session must be at least 50 minutes, including the patient and their independent historian. During the session, a clinician must perform the following 10 elements during the cognitive assessment:
The care plan should include the following:
The care plan should also be shared with the patient and their caregiver.
Note that some of the service elements under 99483 overlap with services under some E/M codes. Therefore, CPT code 99483 cannot be billed on the same day as the following:
Chronic Care Management (CCM) can be used in conjunction with CACP code 99483 or even as part of ongoing follow-up care if the patient has two or more conditions that meet eligibility requirements. This can include Alzheimer’s disease and related dementias that may coexist with another condition, such as diabetes, heart disease, cancer, depression, and numerous others.
Revisions of a patient’s care plan that do not include all the service elements of 99483 could be reported via CCM. Additionally, patients and their family caregivers benefit from regular medication management, care coordination, patient engagement and education, as well as goal-setting.
Because follow-up communication is conducted via phone or telemedicine, caregivers can participate more easily, which makes ongoing care more accessible.
Behavioral Health Integration is another monthly service that can complement CPCP and CCM for patients with cognitive impairment who could benefit from additional support for both physical and mental conditions.
The Guiding an Improved Dementia Experience Model runs from 2024 through 2032. With 390 participating organizations, GUIDE is one of the first Innovation Center care models to focus on longitudinal, condition-specific, comprehensive care.
It supports Medicare beneficiaries living with dementia and their unpaid caregivers through:
While closed to new participants, the GUIDE Model establishes a standard approach to comprehensive, coordinated dementia care through nine clinical and non-clinical service components, including:
ThoroughCare is built upon evidence-based assessments and workflows, as well as clinical and billing requirements that match CMS guidelines for fully implementing and scaling programs, such as Medicare Annual Wellness Visits, Chronic Care Management, and Advance Care Planning.
For cognitive and behavioral needs, similar to those in CACP and GUIDE requirements, ThoroughCare supports service delivery via assessments, including:
ThoroughCare also provides guided care plan development that includes required documentation for billing, including:
Robust analytics enable oversight of individual and population health for patients enrolled in any program, with the ability to filter for those diagnosed with dementia. Through dashboards and reports, such as population health, patient stratification, and annual wellness details, care managers and clinicians can identify concerning trends and focus on interventions for patients at risk.
There are a growing number of programs that CMS supports with reimbursement, such as the following:
Each of these programs aims to diagnose and treat cognitive impairment and dementia earlier and provide care coordination, engagement, and education to patients and their unpaid caregivers.