Journal of Gerontological Nursing

AGS Update 

Cracking the (Reimbursement) Code: New Editorial Outlines a Decade of Hard Work, Big Changes to Advance Covering the Care We Need as We Age

Laurie G. Jacobs, MD, AGSF

Abstract

For millions of older adults who rely on Medicare, the federal health insurance program for individuals 65 and older, the process happens seamlessly and almost always behind the scenes: The care we receive from expert clinicians becomes five-digit “billing codes,” which in turn ensure nurses, physicians, and other health professionals can be reimbursed for work supporting health, safety, and independence for older adults. But even billing codes have a story to tell—and an important one at that, as experts from the American Geriatrics Society (AGS) describe in a new Journal of the American Geriatrics Society editorial (Hollman, Zorowitz, Lundebjerg, Goldstein, & Lazaroff, 2018). The editorial outlines how several key health services—from those for managing chronic care to those for assessing cognitive health—came to be recognized as part of Medicare through an important but oft unsung facet of geriatrics expertise: Its leaders' engagement in building a better public policy environment to support the care we all need as we age (Hollman et al., 2018).

It is hard to believe, but as recently as the late 1990s, Medicare lacked the means to reimburse or even recognize several core services essential to older Americans (Hollman et al., 2018). In reviewing which forces and what players were instrumental to AGS–led change from then to now, the editorial's authors—and the AGS more broadly—hope geriatrics health professionals and older adults alike will have a better appreciation for what it takes to improve care by making sure it can be recognized, particularly at a time when more of us than ever before will need access to new, innovative health services.

As the editorial authors explain, much of that work began with an investment by the AGS of time, talent, and resources in two important entities: the Current Procedural Terminology (CPT®) Editorial Panel and the Relative Value Scale Update Committee (RUC), both coordinated by the American Medical Association (AMA) (Hollman et al., 2018).

Although you may not know the CPT Editorial Panel or RUC by name, you are certainly familiar with their work. Respectively, they develop and continually review billing (or CPT) codes for health services and procedures and ensure reimbursement for those codes accurately reflects provider work (AMA, 2018a). Together, these groups shape what services Medicare will cover (and at what value) from one year to the next (AMA, 2018a,b; Hollman et al., 2018).

The AGS editorial presents a case study in working with groups such as the CPT Editorial Panel and the RUC to ensure our clinicians are able to implement best practices in health care, because these services can be tracked and reimbursed appropriately (Hollman et al., 2018). Around 2011, the AGS became actively involved in the work of the CPT Editorial Panel and RUC (Hollman et al., 2018). Since then, and with significant support from the AMA and several key medical societies, the AGS has been instrumental in securing recognition and reimbursement for several of today's most important geriatrics services (Table).…

For millions of older adults who rely on Medicare, the federal health insurance program for individuals 65 and older, the process happens seamlessly and almost always behind the scenes: The care we receive from expert clinicians becomes five-digit “billing codes,” which in turn ensure nurses, physicians, and other health professionals can be reimbursed for work supporting health, safety, and independence for older adults. But even billing codes have a story to tell—and an important one at that, as experts from the American Geriatrics Society (AGS) describe in a new Journal of the American Geriatrics Society editorial (Hollman, Zorowitz, Lundebjerg, Goldstein, & Lazaroff, 2018). The editorial outlines how several key health services—from those for managing chronic care to those for assessing cognitive health—came to be recognized as part of Medicare through an important but oft unsung facet of geriatrics expertise: Its leaders' engagement in building a better public policy environment to support the care we all need as we age (Hollman et al., 2018).

It is hard to believe, but as recently as the late 1990s, Medicare lacked the means to reimburse or even recognize several core services essential to older Americans (Hollman et al., 2018). In reviewing which forces and what players were instrumental to AGS–led change from then to now, the editorial's authors—and the AGS more broadly—hope geriatrics health professionals and older adults alike will have a better appreciation for what it takes to improve care by making sure it can be recognized, particularly at a time when more of us than ever before will need access to new, innovative health services.

As the editorial authors explain, much of that work began with an investment by the AGS of time, talent, and resources in two important entities: the Current Procedural Terminology (CPT®) Editorial Panel and the Relative Value Scale Update Committee (RUC), both coordinated by the American Medical Association (AMA) (Hollman et al., 2018).

Although you may not know the CPT Editorial Panel or RUC by name, you are certainly familiar with their work. Respectively, they develop and continually review billing (or CPT) codes for health services and procedures and ensure reimbursement for those codes accurately reflects provider work (AMA, 2018a). Together, these groups shape what services Medicare will cover (and at what value) from one year to the next (AMA, 2018a,b; Hollman et al., 2018).

The AGS editorial presents a case study in working with groups such as the CPT Editorial Panel and the RUC to ensure our clinicians are able to implement best practices in health care, because these services can be tracked and reimbursed appropriately (Hollman et al., 2018). Around 2011, the AGS became actively involved in the work of the CPT Editorial Panel and RUC (Hollman et al., 2018). Since then, and with significant support from the AMA and several key medical societies, the AGS has been instrumental in securing recognition and reimbursement for several of today's most important geriatrics services (Table).

Reimbursement and Current Procedural Terminology (CPT) Codes for Geriatric Servicesa

Table:

Reimbursement and Current Procedural Terminology (CPT) Codes for Geriatric Services

As for what lies immediately ahead: the Centers for Medicare & Medicaid Services' proposed Medicare Physician Fee Schedule for 2019 (which outlines changes to payment policies for the upcoming calendar year) included some sweeping—and disconcerting—changes to evaluation and management codes, which encompass many of the core services health professionals provide in routine office visits. The AGS recently submitted comments to CMS and influential Congressional leaders regarding these changes. To access the full comment letter as well as more information on AGS' efforts to improve Medicare, Medicaid, and payment and services for older adults, visit AmericanGeriatrics.org/Where-We-Stand/Medicare-Medicaid.

Laurie G. Jacobs, MD, AGSF

President, American Geriatrics Society

References

Reimbursement and Current Procedural Terminology (CPT) Codes for Geriatric Servicesa

ServiceDescriptionCPT Code(s)Year Recognized for Reimbursement by Medicare
Transitional care managementNon-face-to-face services to help older adults transition from a hospital stay to care at another health facility or home99495; 994962013
Chronic care managementCare addressing the medical, psychological, and social needs of older adults receiving long-range treatment for two or more chronic health concerns994902015
Complex chronic care managementAn elevated level of chronic care management for older adults who require substantial revisions to care plans or have particularly complex decision-making needs99487; 994892017
Cognitive assessment and care plan servicesA thorough evaluation of medical, psychological, and social factors for older adults exhibiting signs of cognitive impairment, as well as efforts to develop care and education plans994832017
Authors

The author has disclosed no potential conflicts of interest, financial or otherwise.

Copyright © 2018 American Geriatrics Society.

10.3928/00989134-20181010-07

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