![]() You’re required to check for cognitive impairment as part of the AWV. How Do I Bill for Cognitive Assessment & Care Plan Services? Service Referral to community resources as needed (for example, rehabilitation services, adult day programs, support groups) shared with the patient or caregiver with initial education and support.The care plan includes initial plans to address: You’ll use information gathered during a cognitive assessment to help you create a written care plan. What Care Plan Services Result from the Assessment? Address Advance Care Planning and any palliative care needs.Identify social supports including how much caregivers know and are willing to provide care.Conduct a safety evaluation for home and motor vehicle operation.Use standardized screening instruments to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety.Reconcile and review for high-risk medications, if applicable.Use standardized instruments for staging of dementia like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR).Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity.Record and review the patient’s history, reports, and records.Examine the patient with a focus on observing cognition.Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment: An independent historian can be a parent, spouse, guardian, or other individual who provides patient history when a patient isn’t able to provide complete or reliable medical history. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483. The cognitive assessment includes a detailed history and patient exam. What’s Included in a Cognitive Assessment? You can perform the assessment at any of these locations: Where Can I Perform the Cognitive Assessment? If you detect cognitive impairment at an AWV or other routine visit, you may perform a more detailed cognitive assessment and develop a care plan during a separate visit. This additional evaluation may be helpful to diagnose a person with dementia, such as Alzheimer’s disease, and to identify treatable causes or co-occurring conditions such as depression or anxiety.Īny clinician eligible to report evaluation and management (E/M) services can offer this service. You may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment. 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. If your patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit to more thoroughly assess your patient’s cognitive function and develop a care plan – use CPT code 99483 to bill for this service.Īs of January 1, 2022, Medicare pays approximately $283 (may be geographically adjusted) for these services when provided in an office setting.ĭetecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). If you're a person with Medicare, learn more about your Medicare coverage for Cognitive Assessment & Care Plan Services.
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