Cognitive assessment and care plan services are provided when a comprehensive evaluation of a new or existing patient, who exhibits signs and/or symptoms of cognitive impairment, is required to establish or confirm a diagnosis, etiology, and severity for the condition.
Eligible Provider
Required Elements to bill CPT 99483
- Cognition-focused evaluation including a pertinent history and examination.
- Medical decision-making of moderate or high complexity.
- Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity.
- Use of standardized instruments for the staging of dementia (eg, 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, including use of standardized screening instrument(s).
- Evaluation of safety (eg, home), including motor vehicle operation.
- Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks.
- Development, updating or revision, or review of an Advance Care Plan.
- Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.
- Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver.
- E/M services - 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99366, 99367, 99368, 99497, 99498.
- Psychiatric diagnostic procedures 90785, 90791, 90792.
- Brief emotional/behavioral assessment - 96127.
- Psychological or neuropsychological test administration 96146.
- Health risk assessment administration 96160, 96161.
- Medication therapy management services 99605, 99606, 99607.