Examine the patient with a focus on observing cognition.Typically, you would spend 60 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? Who Can Offer a Cognitive Assessment?Īny clinician eligible to report evaluation and management (E/M) services can offer this service. 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. 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.
How Do I Get Started?ĭetecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). 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, 2024, Medicare pays approximately $268 (may be geographically adjusted) for these services when provided in an office setting. If you're a person with Medicare, learn more about your Medicare coverage for Cognitive Assessment & Care Plan Services.