Billing and Coding: Cognitive Assessment and Care Plan Service

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 L39266.

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.

**DOCUMENTATION**

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(C) 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+(C) 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 care planning toolkit is a
comprehensive resource that many practitioners will find very helpful.
[Cognitive Impairment Care Planning Toolkit
(alz.org)](https://www.alz.org/careplanning/downloads/care-planning-
toolkit.pdf)

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.

**Diagnosis Coding:**

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.

**CPT Coding:**

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:

90785

90791

90792

96127

96146

96160-96161

99605-99607

99202-99215

99242

99243

99244  

99245

99341

99342  

99344  

99345  

99347  

99348  

99349  

99350

99366-99368

99497

99498