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Prepare to introduce dementia care in 2017 with a two-part service

Practices that assess dementia among patients and create a care plan will find a new payment opportunity in 2017, but you'll have to meet strict reporting requirements to get your claims through.

Look to a new HCPCS code - G0505 - that will pay about $238 for the service, according to the final 2017Medicare physician fee schedule. But ensure you're ready to hit the bullet points before you dive in.

"There are 10 required elements for the service, and all 10 must be performed in order for the code to be reported," explains Peter Hollman, M.D., speaking at the 2017 AMA Symposium in Chicago.

The service elements require a cognition-focused evaluation, functional assessment, medical decision-making that's of moderate or high complexity and use of a standardized instrument to stage dementia, among others.

When it comes to meeting the reporting elements, "you can think of it as two distinct services," says Hollman. On the one hand are the reporting elements that are similar to E/M services; on the other is the development of a care plan.

The care plan must include a documented path "to address any neuropsychiatric symptoms and referral to community resources," and providers are required to share the plan "with the patient and/or caregiver with initial education and support," according to the code description.

While the documentation elements may be formidable, Hollman calls it "a fairly significantly valued code," which may make it attractive to practices that see a high number of elderly patients.

Keep these reporting elements in mind

You're restricted from billing G0505 with a number of CPT codes, including a range of psychotherapy codes and behavioral assessment codes - 90785, 90791, 90792, 96103, 96120 and 96127.

Also excluded are home visit codes (99341-99350) and advance care planning codes (99497, 99498), "because these codes all reflect face-to-face services provided by the physician or other billing practitioner for related services that are separately payable," explains Hollman.

Note other exclusions: You're not eligible to bill office visit codes for either new or established patients on the same date of service. That means 99201-99215 are off the table.

Note allowances for care management: On the other hand, you can bill the dementia care code during the same billing period that you report chronic care management (CCM) and transitional care management (TCM) services, notes Hollman. You're also eligible to report G0505 with the behavioral health integration (BHI) codes that are also launching Jan. 1.

A look at the official description

Note the official code description for G0505: "Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the physician or other qualified health care professional in the office or other outpatient setting or home or domiciliary or rest home."

The full list of required elements encompasses:
  • Cognition-focused evaluation including a pertinent history and examination.
  • Medical decision-making of moderate or high complexity, defined by the E/M guidelines.
  • Functional assessment -- for example, basic and instrumental activities of daily living -- including decision-making capacity.
  • Use of standardized instruments to stage dementia.
  • Medication reconciliation and review for high-risk medications, if applicable.
  • Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized instrument(s).
  • Evaluation of safety (for example, home), 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, support groups); care plan shared with the patient and/or caregiver with initial education and support.
What if you report only some, say, nine out of the 10, service elements? You'll have to "report another E/M code," advises Hollman. The requirements demand the full slate.
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