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Table 1.  Use of CACP Among Medicare Fee-for-Service Patients in 2017 and 2018
Use of CACP Among Medicare Fee-for-Service Patients in 2017 and 2018
Table 2.  Association Between Patient Characteristics and CACP Use Among Medicare Fee-for-Service Patients With ADRD, 2017-2018
Association Between Patient Characteristics and CACP Use Among Medicare Fee-for-Service Patients With ADRD, 2017-2018
1.
Owens  DK, Davidson  KW, Krist  AH,  et al; US Preventive Services Task Force.  Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement.   JAMA. 2020;323(8):757-763. doi:10.1001/jama.2020.0435PubMedGoogle Scholar
2.
Livingston  G, Sommerlad  A, Orgeta  V,  et al.  Dementia prevention, intervention, and care.   Lancet. 2017;390(10113):2673-2734. doi:10.1016/S0140-6736(17)31363-6PubMedGoogle ScholarCrossref
3.
Borson  S, Boustani  M, Chodos  A,  et al. Cognitive assessment and care planning services: Alzheimer’s Association Expert Task Force recommendations and tools for implementation. 2018. Accessed April 20, 2021. https://www.alz.org/careplanning/downloads/cms-consensus.pdf.
4.
Harrison  KL, Adrion  ER, Ritchie  CS, Sudore  RL, Smith  AK.  Low completion and disparities in advance care planning activities among older Medicare beneficiaries.   JAMA Intern Med. 2016;176(12):1872-1875.PubMedGoogle ScholarCrossref
5.
Centers for Medicare & Medicaid Services. CMS Chronic Conditions Data Warehouse (CCW) Condition Algorithms. 2021. Accessed April 20, 2021. https://www.ccwdata.org/documents/10280/19139421/ccw-chronic-condition-algorithms.pdf.
6.
Ganguli  I, Souza  J, McWilliams  JM, Mehrotra  A.  Practices caring for the underserved are less likely to adopt Medicare’s annual wellness visit.   Health Aff (Millwood). 2018;37(2):283-291. doi:10.1377/hlthaff.2017.1130PubMedGoogle ScholarCrossref
Research Letter
Health Policy
September 17, 2021

Use of Medicare’s New Reimbursement Codes for Cognitive Assessment and Care Planning, 2017-2018

Author Affiliations
  • 1Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
  • 2Mailman School of Public Health, Columbia University, New York, New York
  • 3Harvard Medical School, Boston, Massachusetts
  • 4Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
  • 5Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Netw Open. 2021;4(9):e2125725. doi:10.1001/jamanetworkopen.2021.25725
Introduction

Substantial barriers exist in timely detection of cognitive impairment, especially Alzheimer disease and related dementias (ADRD), impeding effective care planning and coordination among providers, patients and caregivers.1,2 To address these challenges, on January 1, 2017, Medicare began reimbursing clinicians for a comprehensive clinical visit for patients with cognitive impairment. Reimbursement requires cognition-focused evaluation, identification of caregivers and caregiver needs, and development, revision, or review of an Advance Care Plan.3,4 We provided the first assessment of the use of the new cognitive assessment and care planning (CACP) codes in the first 2 years of their introduction.

Methods

The study was approved by the institutional review board of Weill Cornell Medical College. Informed consent was not obtained because only deidentified secondary data were used. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

We conducted a retrospective cross-sectional study using a 20% nationwide random sample of Medicare Part A and B claims and Medicare Beneficiary Summary File. Our study population included Medicare fee-for-service patients aged 65 years or older as of 2017 who were continuously enrolled in Medicare Part A and B between 2017 and 2018, or until death if they died during this period. Use of CACP was identified using Current Procedural Terminology code G0505 in 2017 and 99483 in 2018. We assessed the prevalence of patients with CACAP claims. Because patients with ADRD were the primary recipients of CACP, we stratified the claims by whether the patients had a diagnosis of ADRD in either 2017 or 2018 that had been identified by using the ADRD chronic condition indicator in the Medicare Beneficiary Summary File. Among patients with ADRD, we used multivariable logistic regression analysis to identify patient characteristics associated with having CACP in either 2017 or 2018. Patient characteristics included: age (ie, 65-74 years, 75-84 years, ≥85 years), gender, race, region of residence (ie, South, Midwest, West, Northeast), dual eligibility for Medicare and Medicaid, income quartile, and number of non-ADRD chronic conditions.5 P values were calculated using 2-sided t test, with .05 as the level of significance. Statistical analyses were performed from August 2020 to March 2021. SAS version 9.4 (SAS Institute) was used for all data analyses.

Results

Our study population included 5 980 271 Medicare patients, and 895 726 of the patients (15.0%) had ADRD and 8355 of the patients (0.14%) had at least 1 CACP claim in either 2017 or 2018 (Table 1). Among patients with ADRD, 390 116 (43.5%) were aged 85 years or older, 358 500 (40.0%) resided in the South, 234 638 (26.2%) were Medicaid eligible, and 565 042 (63.1%) had at least 5 chronic conditions other than ADRD (Table 2).

Among ADRD patients, 5796 patients (0.65%) had a CACP claims in either 2017 or 2018. The proportion patients with CACP claims increased from 2017 to 2018 for patients with ADRD and without ADRD (2017: patients with ADRD, 2619 [0.29%]; patients without ADRD, 1274 [0.03%]; 2018: patients with ADRD, 3639 [0.41%]; patients without ADRD, 1511 [0.03%]), and 688 (8.23%) who received any CACP services received them in both 2017 and 2018.

In an adjusted analysis, patients who were aged 85 years or older (odds ratio [OR] 0.69; 95% CI, 0.64-0.74), resided in the Midwest relative to the South (OR, 0.42; 95% CI, 0.38-0.46), and were eligible for Medicaid (OR, 0.59; 95% CI, 0.55-0.63) were associated with lower odds of having a CACP claim (Table 2). Patients were associated with higher odds of having CACP if they resided in the West relative to South, were in a higher income quartile, and had more chronic medical conditions.

Discussion

There was a very low uptake of CACP claims in the first 2 years after its introduction, with disparities by patient age, number of chronic conditions, region, and income. Patients who are older may encounter more challenges in fulfilling the comprehensive evaluation required by CACP, and providers may prioritize CACP among those with more chronic conditions. Furthermore, providers in rural areas or small practices may be less likely to be aware of these codes, which may disproportionately affect patients in more remote geographic areas or patients with a lower socioeconomic status.6 However, it is possible that providers were billing components of the CACP service under separate reimbursement codes. Because of data limitations, we were unable to examine Medicare Advantage patients or include more recent years. However, our study suggests that increasing provider awareness of the new CACP service is important, perhaps through targeted continuing medical education at the facility level which may also address institution-specific challenges in billing CACP.

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Article Information

Accepted for Publication: July 15, 2021.

Published: September 17, 2021. doi:10.1001/jamanetworkopen.2021.25725

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Li J et al. JAMA Network Open.

Corresponding Author: Jing Li, PhD, Assistant Professor, Department of Population Health Sciences, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065 (jil2033@med.cornell.edu).

Author Contributions: Dr Li had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Li, Mitchell.

Acquisition, analysis, or interpretation of data: Li, Andy.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Li.

Statistical analysis: Li, Andy.

Obtained funding: Li.

Supervision: Li, Mitchell.

Conflict of Interest Disclosures: Dr Li reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr Li was supported by grant K01AG066946 from the National Institute on Aging of the National Institutes of Health.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Owens  DK, Davidson  KW, Krist  AH,  et al; US Preventive Services Task Force.  Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement.   JAMA. 2020;323(8):757-763. doi:10.1001/jama.2020.0435PubMedGoogle Scholar
2.
Livingston  G, Sommerlad  A, Orgeta  V,  et al.  Dementia prevention, intervention, and care.   Lancet. 2017;390(10113):2673-2734. doi:10.1016/S0140-6736(17)31363-6PubMedGoogle ScholarCrossref
3.
Borson  S, Boustani  M, Chodos  A,  et al. Cognitive assessment and care planning services: Alzheimer’s Association Expert Task Force recommendations and tools for implementation. 2018. Accessed April 20, 2021. https://www.alz.org/careplanning/downloads/cms-consensus.pdf.
4.
Harrison  KL, Adrion  ER, Ritchie  CS, Sudore  RL, Smith  AK.  Low completion and disparities in advance care planning activities among older Medicare beneficiaries.   JAMA Intern Med. 2016;176(12):1872-1875.PubMedGoogle ScholarCrossref
5.
Centers for Medicare & Medicaid Services. CMS Chronic Conditions Data Warehouse (CCW) Condition Algorithms. 2021. Accessed April 20, 2021. https://www.ccwdata.org/documents/10280/19139421/ccw-chronic-condition-algorithms.pdf.
6.
Ganguli  I, Souza  J, McWilliams  JM, Mehrotra  A.  Practices caring for the underserved are less likely to adopt Medicare’s annual wellness visit.   Health Aff (Millwood). 2018;37(2):283-291. doi:10.1377/hlthaff.2017.1130PubMedGoogle ScholarCrossref
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