Cracking the (Reimbursement) Code: Editorial Outlines Hard Work, Big Changes to Advance Geriatric Care

A recent editorial in the Journal of the American Geriatrics Society (online September 17, 2018. doi:10.1111/jgs.15593) 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 and long-term care expertise: its leaders’ engagement in building a better public policy environment to support the care we all need as we age.

“It’s hard to believe but as recently as the late 1990s, Medicare—our primary federal insurer for older people—lacked the means to reimburse or even recognize several core services essential to older Americans,” noted Peter Hollmann, MD, AGSF, American Geriatrics Society (AGS) treasurer and one of the lead authors for the retrospective editorial. “In reviewing which forces and what players were instrumental to AGS-led change from then to now, we 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.”

As the editorial authors explain, much of that work began with AGS’ investment 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).

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 codes (referred to as “CPT codes”) for health services and procedures and ensure reimbursement for those codes accurately reflect provider work. Together, these groups shape what services Medicare will cover (and at what value) from one year to the next.

The AGS editorial presents a case study in working with groups like the CPT Editorial Panel and the RUC to ensure our clinicians are able to implement best practices to health care because these services can be tracked and reimbursed appropriately. Around 2011, the AGS became actively involved in the work of the CPT Editorial Panel and RUC. 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. These include:

Transitional Care Management, which describes non-face-to-face services to help older people transition from a hospital stay to care at another health facility or at home (CPT codes 99495 and 99496);

Chronic Care Management, which describes care addressing the medical, psychological, and social needs of older people receiving long-range treatment for two or more chronic health concerns (CPT code 99490);

Complex Chronic Care Management, which describes an elevated level of chronic care management for older people who require substantial revisions to care plans or who have particularly complex decision-making needs (CPT codes 99487 and 99489); and

Cognitive Assessment and Care Plan Services, which describes a thorough evaluation of medical, psychological, and social factors for older people exhibiting signs of cognitive impairment, as well as efforts to develop care and education plans (CPT code 99483).

“In working to develop, review, and ensure approval for these codes and other components of our public policy work, we’ve learned a great deal—particularly about the importance of a clear vision to improve health, safety, and independence for older people,” Dr Hollmann observed. “We set out in the 1990s to achieve appropriate payment for the care of older people. We are proud of our successes to-date, but we also recognize the need to better describe and value the work for geriatrics health professionals moving forward.”

The AGS editorial, “Hard Work, Big Changes: AGS Efforts to Improve Payment for Geriatrics Care” is available for free from Journal of the American Geriatrics Society.