Primary Care Coding Alert

And take note of all these validated cognitive assessment tools.

If you’ve ever used 99483 (Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home …) to document a provider’s assessment and care planning for a patient with dementia, you’ll know there’s a lot to unpack just in the code descriptor alone. CPT^® lists at least 10 elements of assessment and care planning that must be satisfied before you can bill the service.

And that’s just the tip of the 99483 iceberg. Here’s everything else you need to know to make sure your dementia patients get the care they need, and you get the financial reimbursement you deserve for the work.

Begin Here With Medicare Patients

Before you automatically reach for 99483 to code a cognitive assessment of a patient with suspected dementia, remember there may be another option. For Medicare patients, screening for dementia often begins as a part of the initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit; or an annual wellness visit (AWV), coded to G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit) or G0439 (Annual wellness visit … subsequent visit), respectively. That’s because one of the components of both the IPPE and AWV involves assessing the patient’s “cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others” according to the Medicare Learning Network website Medicare Wellness Visits.

Then Move to 99483 When Cognitive Impairment Is Detected

If the IPPE or AWV reveals “signs and/or symptoms of cognitive impairment,” or if those signs and/or symptoms are exhibited by any “new or existing patient,” your PCP will then want to “provide cognitive assessment … to establish or confirm a diagnosis, etiology and severity for the condition” as well as establishing care plan services, according to CPT^®.

That’s where 99483 comes in, with its10 elements that must be performed or be “deemed necessary for the patient’s condition,” per CPT^®. In fact, there are 11 elements to the code if you count the input of an independent historian, defined by CPT^® as “an individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.”

Aid Assessment With These Validated Tools

Essentially, 99483 involves a full assessment of the patient, including an examination and histories taken from the patient, if possible, and the independent historian. The assessment should also take results obtained from validated tools into account. In their Cognitive Impairment Care Planning Toolkit, the Alzheimer’s Association suggests the provider consider assessing the following cognitive domains using the accompanying instruments, though other, more complex tools may be necessary dependent on the patient’s current situation:

• Cognition: Mini-Cog^Ó, General Practitioner Assessment of Cognition (GPCOG), Montreal Cognitive Assessment (MoCA)
• Function: Katz Index of Independence in Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living Scale (IADL), functional activities questionnaire (FAQ). These should all be rated by the patient’s caregiver.
• Stage of cognitive impairment: Dementia Severity Rating Scale (DSRS). This should also be rated by the patient’s caregiver.
• Neuropsychiatric symptoms and depression: Neuropsychiatric Inventory Questionnaire (NPI-Q), BEHAV5+, Patient Health Questionnaire (PHQ)-2
• Safety: Alzheimer’s Association Safety Assessment Checklist. This can be rated by the patient or caregiver.

In addition, the provider should create a list of the patient’s current medications with the name of the person overseeing them, and should obtain a completed PHQ-2 and caregiver profile checklist from the patient’s caregiver.

Then Document the Care Plans

The descriptor for 99483 also tells you the provider needs to document two distinctly different care plans.

The written care plan, as the Alzheimer’s Association’s Cognitive Impairment Care Planning Toolkit highlights, should contain some, or all, of the following components as appropriate to the patient:

• “Specific characteristics of the cognitive disorder (e.g., type and severity of cognitive impairment; special hazards such as falls or orthostatic hypotension in Lewy body dementia; or referral to a dementia specialist for further diagnostic assessment or complex management).
• “Management of any neuropsychiatric symptoms, including referrals for caregiver stress and behavior management training or psychiatric care for the patient as indicated.
• “Comorbid medical conditions and safety management, including any changes needed to accommodate the effects of cognitive impairment.
• “Caregiver stress and support needs, including primary care counseling and, as indicated, referrals to community-based education and support, specialized individual or family counseling, or in-home care, legal or financial assistance.”

The Alzheimer’s Association recommends the care plan should “should be written in language that is easily understood, indicate who has responsibility for carrying out each recommended action step and specify an initial follow-up schedule.” It should be filed in the patient’s medical record and shared with the patient’s family and/or caregiver, and “other providers caring for the patient,” with permission to share with them documented in the record.

The advanced care plan (ACP), as the Medicare Learning Network (MLN) fact sheet Advance Care Planning explains, “is a voluntary, face-to-face discussion between you and your patient, their family member, caregiver, or surrogate (as appropriate) to discuss the patient’s health care wishes if they become unable to make their own medical decisions.” This includes discussing, though not necessarily completing, legal forms for some or all of the patient’s wishes regarding:

• Do not resuscitate (DNR) orders
• Healthcare powers of attorney
• Healthcare proxies
• Instruction directives
• Living wills
• Medical orders for life-sustaining treatment (MOLST)
• Psychiatric advance directive (PAD)

Remember 1: As this ACP discussion duplicates the discussion described in 99497 (Advance care planning … first 30 minutes) and add-on +99498 (… each additional 30 minutes), you will not be able to bill for ACP services separately, as CPT^® instructions for billing 99483 tell you.

And Keep an Eye on the Clock and the Calendar

As if documenting all of the above wasn’t enough, you will also need to document the amount of time your provider spent on providing 99483 services. The base code itself allows you to bill for 60 minutes of service time, but once the provider goes over 75 minutes, you’ll add a unit of +99417 (Prolonged outpatient evaluation and management service(s) time … each 15 minutes of total time …), adding additional units of +99417 for every 15 minutes beyond that time.

Remember 2: Per CPT^® instructions for the code, “a single physician or other qualified health care professional should not report 99483 more than once every 180 days.”

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC