HCPCS Code Spotlight – New Dementia Care Management Codes

Dementia affects more than 6.7 million Americans and is projected to reach 14 million cases by 2060.  In response to these projections, the Centers for Medicare and Medicaid Services (CMS) launched the GUIDE (Guiding an Improved Dementia Experience) Model last summer to focus on transforming dementia care management.  The primary goals of the GUIDE Model are to improve the quality of life for people living with dementia, reduce burden on unpaid caregivers, and support people living with dementia to remain independent in their homes and communities. 

CMS is testing an alternative payment model for accepted participants that delivers key supportive services to people with dementia, including comprehensive, person-centered assessments and care plans, care coordination, and 24/7 access to a support line. Under the GUIDE model, participants will assign people with dementia and their caregivers to a care navigator who will help them access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations. Through the GUIDE Innovation Model, alternative reimbursement will now be provided via dementia care coordination and care management, caregiver education and support, and respite services.  Please note, the GUIDE model is a participation-based program and GUIDE services are not reimbursable through traditional fee-for-service billing.  The GUIDE model launched on July 1, 2024, and will continue for the next 8 years.

The new HCPCS codes to support the GUIDE model were introduced with the HCPCS quarterly release on 7/1/24 and include:

G0519 – Management of new patient-caregiver dyad with dementia, low complexity, for use in CMMI model

G0520 – Management of new patient-caregiver dyad with dementia, moderate complexity, for use in CMMI model

G0521 – Management of new patient-caregiver dyad with dementia, high complexity, for use in CMMI model

G0522 – Management of a new patient with dementia, low complexity, for use in CMMI model

G0523 – Management of a new patient with dementia, moderate to high complexity, for use in CMMI model

G0524 – Management of established patient-caregiver dyad with dementia, low complexity, for use in CMMI model

G0525 – Management of established patient-caregiver dyad with dementia, moderate complexity, for use in CMMI model

G0526 – Management of established patient-caregiver dyad with dementia, high complexity, for use in CMMI model

G0527 – Management of established patient with dementia, low complexity, for use in CMMI model

G0528 – Management of established patient with dementia, moderate to high complexity, for use in CMMI model

G0529 – In-home respite care, 4-hour unit, for use in CMMI model

G0530 – Adult day center, 8-hour unit, for use in CMMI model

G0531 – Facility-based respite, 24-hour unit, for use in CMMI model

Learn more about the CMS GUIDE Innovation Model here:  https://www.cms.gov/priorities/innovation/innovation-models/guide

https://www.cms.gov/files/document/guide-payment-methodology-paper.pdf

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