The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cognitive Assessment and Care Plan Service DL39266.
Code 99483 provides reimbursement to physicians and other eligible billing practitioners for a comprehensive clinical visit that results in a written care plan.
All beneficiaries who are cognitively impaired are eligible to receive the services under this code. This includes those who have been diagnosed with Alzheimer’s, other dementias, or mild cognitive impairment. It also includes those individuals without a clinical diagnosis who, in the judgment of the clinician, are cognitively impaired.
Screening for cognitive impairment is still a requirement of Medicare Annual Wellness Visits (AWV). However, cognitive impairment can also be identified as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. You may perform a more detailed cognitive assessment and develop a care plan during a separate visit.
CPT code 99483 is generally billed separately from the annual wellness visit due to the time, complexity and medical decision making inherent to this service. However, if the AWV and Cognitive Assessment and Care plan services are done at the same visit, a -25 modifier would need to be appropriately utilized.
Code 99483 requires an independent historian in order to correctly perform the assessments and develop a corresponding care plan under CPT code 99483. An independent historian can be a parent, spouse, guardian, or any other individual who can provide patient history when a patient is not able to supply complete or reliable information.
Required service elements for CPT code 99483 include ALL of the following:
- Cognition-focused evaluation, including a pertinent history and examination;
- Medical decision making of moderate or high complexity;
- Functional assessment (e.g., Basic and Instrumental Activities of Daily Living), including decision-making capacity;
- Use of standardized instruments to stage dementia (e.g., Functional Assessment Staging Test [FAST], Clinical Dementia Rating [CDR]);
- Medication reconciliation and review for high-risk medications;
- Evaluation for neuropsychiatric and behavioral symptoms, including depression and including use of standardized instruments;
- Evaluation of safety, at home and otherwise, including motor vehicle operation, if applicable;
- Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports and willingness of caregiver to take on caregiving tasks;
- Development, with periodic updating/revision/review of an Advance Care Plan;
- Creation of a written care plan which includes initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed. This care plan must be documented as having been shared with the patient and/or caregiver at the time of initial education and support.
The components noted above are central to informing, designing and delivering a care plan suitable for patients with cognitive impairment.
Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver for this service.
Do not report cognitive assessment and care plan services if any of the required service elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management (E/M) code.
The documentation of cognitive-relevant history should include any factors that could be contributing to cognitive impairment such as, but not limited to, psychoactive medications, chronic pain syndromes, infection, depression, and other brain diseases.
The documentation of medical decision making should include current and likely progression of the patient’s disease, the need for referral(s) for rehabilitative, social, legal, financial, or community services including meal/transportation and other personal assistive services.
Identification of patients eligible for this service for whom no diagnosis has yet been firmly established will require excellent documentation that confirms the presence of cognitive impairment and provides the narrative history that spurred suspicion for a potential cognitive impairment diagnosis on the part of the practitioner.
Standardized, validated tools should be used and are required for some elements. Such tools offer a basic framework on which to build a nuanced clinical understanding of care needs through ongoing clinical contact with the patient and caregiver. Though all required elements must be represented, the choice of assessment tools should be customized for differing clinician styles and practice composition, workflows and overall clinical goals. However, all assessment tools utilized must be able to demonstrate standardization, validation and be recognized as such by reputable national specialty organizations. Palmetto GBA reserves the right to review the accuracy, reliability, efficacy, and general credibility of assessment measurement tools utilized. Specific documentation requirements using various standardized measurement tools are noted below. These requirements of course do not preclude the use of additional assessment methods as desired by the individual practitioners.
For any scoring tool assessment performed, the full instrument raw scoring and results must be available for Medicare Administrative Contractor review if requested.
Documentation of cognitive assessment must be present within the medical record. Alzheimer’s Association suggestions for cognitive measurement tools are being adopted by Palmetto GBA as acceptable and reasonable/necessary methods. Thus, assessment of cognition via the Mini-Cog© or GPCOG or Short Montreal Cognitive Assessment (s-MoCA) tools must be documented within the medical record.
A functional assessment of basic and instrumental activities of daily living with either the Katz Index of Independence in Activities of Daily Living or the Lawton-Brody Instrumental Activities of Daily Living Scale (IADL) is required and must be present within the medical record. Use of a standardized instrument for the staging of dementia − either the Functional Assessment Staging Test (FAST scale), Clinical Dementia Rating (CDR® Dementia Staging Instrument), Dementia Severity Rating Scale (DSRS), or Global Deterioration Score (GDS) is required and again must be present within the medical record. These dementia staging tools require the involvement of an independent historian. This historian must be identified within the medical record as having been present and involved.
Decision-making capacity of the patient must be documented within the medical record. Various methods/tools may be used for this assessment. Essentially the decision-making capacity of the patient is based on global clinician judgment. The practitioner should at least note if the patient is able to make their own decisions or is not able to make their own decisions or that decision making capacity is uncertain and will require further evaluation. Final care planning must result in identification of who will be making decisions in the event that the patient cannot.
Because the identification of co-existing neuropsychiatric symptoms or conditions is so important and because this assessment with standardized measure tools is required for the 99483 CPT service, the following Alzheimer’s Association supported tools will be acceptable for purposes of coverage: Neuropsychiatric Inventory Questionnaire (NPI-Q) or BEHAV5+© or Patient Health Questionnaire-2 (PHQ-2). Evidence of use of 1 of these assessment methods must be present within the medical record.
Documentation demonstrating full reconciliation of medications must be present.
Evaluation of safety for home and motor vehicle operation must be documented.
Social supports must be identified and documented. The documentation must be clear as to how much caregivers know about the patient and how much care they are willing to provide. Caregivers should be identified within the record.
Advance Care Planning must be addressed as well as any palliative care needs.
In general, the Alzheimer’s Association’s careplanning toolkit is a comprehensive resource that many practitioners will find very helpful. Cognitive Impairment Care Planning Toolkit (alz.org)
The written care plan should reflect a synthesis of the information acquired as part of the assessment. It should be written in language that is easily understood, indicates who has responsibility for carrying out each recommended action step and specify an initial follow-up schedule.
PROVISION OF THE COGNITIVE ASSESSMENT/PLANNING SERVICE
Any practitioner eligible to report E/M services can provide this service. Eligible providers include physicians (MD and DO), nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), and physician assistants (PA). Eligible practitioners must provide documentation that supports a moderate-to-high level of complexity in medical decision making, as defined by E/M guidelines (with application as appropriate of the usual “incident-to” rules, consistent with other E/M services).
The 10 assessment elements of 99483 can be evaluated within the care planning visit or in 1 or more visits that precede it, using appropriate billing codes (most often an E/M code). Patients with complex medical, behavioral, psychosocial and/or caregiving needs may require a series of assessment visits, while those with well-defined or less complex problems may be fully assessed during the care plan visit. Results of assessments conducted prior to the care plan visit are allowed in care planning documentation provided they remain valid or are updated with any changes at the time of care planning. Palmetto GBA believes that the needed assessments and visits pursuant to the written comprehensive treatment plan should all have occurred within a time period of ≈ 3 months in order to assure relevance of all such assessments to the treatment plan.
Many of the required assessment elements can be completed by appropriately trained members of the clinical team working with the eligible provider. Assessments that require the direct participation of a knowledgeable care partner or caregiver, such as a structured assessment of the patient’s functioning at home or a caregiver stress measure, may be completed prior to the clinical visit and provided to the clinician for inclusion in care planning. Care planning visits can be conducted in the office or other outpatient setting, home, domiciliary or rest home settings, and via telehealth.
Though not required by CPT 99483, the time, complexity and expanse of required elements for this service may lend itself to a standardized care plan template. Such a template can be customized to the provider or health care system in order to simplify communication and tracking of patient care and outcomes over time. However, a template must be easily addressed and edited. Use of a templated document must provide for narrative that is unique and specific to the impacted beneficiary. No specific form or template is required for the written care plan as part of CPT 99483.
The written plan must be discussed with and given to the patient and/or family or caregiver; this face-to-face conversation must be documented in the clinical note for all encounters reported using 99483. The care plan must be filed in the patient’s medical record where it can be easily retrieved and updated. Sharing the plan with other providers caring for the patient, including clinicians, care managers, caseworkers, and others who assist the patient and caregiver, both within and outside the primary care environment is highly recommended as it will help ensure continuity and coordination of care. When such sharing requires explicit consent of the patient, family, caregiver or legally designated decision-maker, that permission should be sought and documented.
Care plans should be revised at intervals and whenever there is a change in the patient’s clinical or caregiving status. Palmetto GBA may audit the frequency of use for CPT 99483. Revisions of a care plan that do not include all the service elements of 99483 could be reported via other E/M codes such as chronic care management or non-face-to-face consultation codes.
A single physician or other qualified health care professional should not report 99483 more than once every 180 days.
99483 services are permanently covered via telehealth. Use CPT code 99483 to bill for both in-person and telehealth services. Although furnished via telehealth, all the required service elements for 99483 must still be present. Proper history acquisition from a corroborating or independent source must still occur.
The condition(s) for which the patient receives Cognitive Assessment and Care Planning should be coded per the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10-CM). When part of a Medical Wellness Visit, the code should report an administrative examination or a well exam diagnosis.
Some of the service elements under 99483 overlap with services under other E/M codes, advance care planning services, and certain psychological or psychiatric service codes per CPT coding directives and/or CMS guidance. As a result, the following CPT codes cannot be reported together with 99483 on the same date of service: