Cognitive Assessment & Care Plan Services

If your Medicare patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit to thoroughly assess your patient’s cognitive function and develop a detailed care plan; use CPT code 99483 to bill for this service.

How Do I Get Started?

We require providers to detect any cognitive impairment the patient may have as part of a patient’s annual wellness visit (AWV). You can also detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others about changes in:

• Memory
• Judgment
• Decision-making
• Medication adherence
• Errors

You may also use a brief cognitive test and evaluate chronic conditions and other factors that contribute to increased risk of cognitive impairment.

If you detect any cognitive impairment at an AWV or another routine visit, you may perform a more detailed cognitive assessment and develop a care plan during a separate visit. This additional evaluation may help diagnose a person with dementia, including Alzheimer’s disease, and identify treatable causes or co-occurring conditions, such as depression or anxiety.

Who Can Offer a Cognitive Assessment?

Clinicians who can report evaluation and management (E/M) services can offer this service. Eligible providers include:

• Physicians (doctor of medicine or doctor of osteopathy)
• Nurse practitioners
• Clinical nurse specialists
• Physician assistants

Where Can I Perform the Cognitive Assessment?

You can perform the assessment in these locations:

• Office or outpatient setting
• Private residence
• Care facility
• Rest home
• Via telehealth

What’s Included in a Cognitive Assessment?

The cognitive assessment includes a detailed history and patient exam. An independent historian must be present to provide history that the patient may not be able to provide completely and reliably. An independent historian can be a parent, spouse, guardian, or another individual.

Typically, you would spend 60 minutes face-to-face with the patient and an independent historian to perform the following elements during the cognitive assessment and care plan services visit:

• Examine the patient with a focus on observing cognition
• Record and review the patient’s history, reports, and records
• Conduct a functional assessment of basic and instrumental activities of daily living, including decision-making capacity
• Use standardized instruments to stage dementia, like the Functional Assessment Staging Test (FAST) and the Clinical Dementia Rating (CDR)
• Reconcile and review for high-risk medications, if applicable
• Use standardized screening instruments to evaluate neuropsychiatric and behavioral symptoms, including depression and anxiety
• Conduct a safety evaluation for home and motor vehicle operation
• Identify social supports, including how much caregivers know and are willing to provide care
• Address advance care planning and any palliative care needs

What Care Plan Services Result from the Assessment?

 You’ll use information you gather during a cognitive assessment to create a written care plan, which includes initial plans to address:

• Neuropsychiatric symptoms
• Neurocognitive symptoms
• Functional limitations
• A referral to community resources as needed (for example, rehabilitation services, adult day programs, and support groups) shared with the patient or caregiver with initial education and support

How Do I Bill for Cognitive Assessment & Care Plan Services?

Service	Code	Things to Know
Initial AWV	HCPCS code G0438	You’re required to check for cognitive impairment as part of the AWV.
Subsequent AWVs	HCPCS code G0439	You’re required to check for cognitive impairment as part of subsequent AWVs.
Assessment of and care planning for patients with any cognitive impairment, like dementia, including Alzheimer’s disease, at any stage of impairment	CPT code 99483	If you detect any cognitive impairment during the AWV or another routine visit, you may perform a more detailed cognitive assessment and care plan.

Billing Requirements for CPT Code 99483

• An independent historian must be present during the visit to bill 99483.
• You may bill 99483 separately from the AWV. If you choose to perform the AWV along with the cognitive assessment and care plan service in the same visit, add modifier 25 to the claim.
• 99483 includes level 5 E/M service CPT code 99215 elements, like:
• A comprehensive history
• A comprehensive exam
• High complexity medical decision-making
• Providers can bill 99483 with the add-on HCPCS code G2212 for a visit that exceeds the 60-minute timeframe.
• Providers can’t bill 99483 on the same day as these services:
• 90785 (Psytx complex interactive)
• 90791 (Psych diagnostic evaluation)
• 90792 (Psych diag eval w/med srvcs)
• 96127 (Brief emotional/behav assmt)
• 96146 (Psycl/nrpsyc tst auto result)
• 96160–96161 (Health risk assessment)
• 99202–99215 (Office/outpatient visits)
• 99341–99350 (Home visits)
• 99497 (Advncd care plan 30 min)
• 99498 (Advncd care plan addl 30 min)

More Information

• Visit the National Institute on Aging’s Alzheimer’s and Related Dementia Resources for Professionals webpage, which includes links to screening tools and assessments

• Refer to our Report to Congress (PDF) for cognitive assessment and care plan services provider outreach and reporting