Cognitive Care Reimbursement Now Part of Medicare Physician Fee Schedule

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The Centers for Medicare & Medicaid Services (CMS) has approved the final physician fee schedule for cognitive care reimbursement in the 2021 Medicare Physician Fee Schedule (MPFS).

While not perfect, says the American College of Rheumatology, there are some positive changes that are effective Jan. 1, 2021.

The final rule provides “much-needed” increases in Medicare reimbursement for the evaluation and management (E/M) services provided by rheumatologists and other cognitive care specialties to Medicare beneficiaries. Healthcare services billed under E/M codes include examinations, disease diagnosis, risk assessments and care coordination.

“For many years, Medicare reimbursement did not adequately reflect the time and skill required to provide high-quality cognitive care, including rheumatology care,” said David Karp, M.D., Ph.D., president of the ACR. “These updates are critical to the future of the rheumatology specialty and the continued delivery of high-quality rheumatology care for millions of Medicare beneficiaries.”

Cognitive impairment affects patients across the rheumatic disease spectrum. In rheumatoid arthritis, for example, prevalence estimates range from 38-71 percent. Systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) are also associated with cognitive dysfunction. In SSc, cognitive dysfunction is most often limited to psychological burden, including depression and anxiety. The theory is that controlling systemic inflammation, combined with behavioral cognitive therapies, may benefit these patients. (Arthritis Res Ther. Published online 2020 Apr 15. doi: 10.1186/s13075-020-02180-5)

In 2018, CMS proposed a code collapse that would have resulted in significant cuts to rheumatology care provided to Medicare beneficiaries. However, after hearing the concerns raised by the patient and specialty provider community, CMS finalized a new proposal that reflects the recommendations of the American Medical Association, the ACR and over 170 other specialty societies and state medical associations.

“These E/M improvements are the result of years of advocacy by rheumatologists and patients that educated policymakers about the importance of time spent with patients for chronic disease management,” said Blair Solow, M.D., chair of the ACR’s Government Affairs Committee. “We commend CMS for recognizing the value of the care provided by rheumatologists and rheumatology health professionals.”

To ensure that long overdue E/M rate increases do not lead to rate cuts to other medical specialties including physical and occupational therapists, the ACR is also leading advocacy efforts in support of H.R. 8505, legislation that would provide for a one-year waiver of budget neutrality adjustments. In November, the ACR led more than 60 groups in sending a letter to Congressional leaders urging them to support the bipartisan legislation, which was introduced by Representatives Michael Burgess (R-TX) and Bobby Rush (D-IL).

“Budget neutrality via H.R. 8505 is a fair and reasonable approach to ensure needed cognitive care updates are not made at the expense of other specialties. We encourage congressional leaders to swiftly pass this legislation,” Dr. Solow said.