There are substantial barriers when it comes to timely detection of cognitive impairment, especially Alzheimer disease and related dementias (ADRD), impeding effective care planning and coordination among providers, patients, and caregivers. As per a recent estimate, 12.7 million people over 65 years of age are projected to have Alzheimer’s by 2050.
So, it’s not surprising that the Centers for Medicare & Medicaid Services (‘CMS’) evaluated its reimbursement for cognitive assessment and care plan services. On January 1, 2017, Medicare began reimbursing clinicians for a comprehensive clinical visit for patients with cognitive impairment.
Reimbursement requires cognition-focused evaluation, identification of caregivers and caregiver needs, and development, revision, or review of an Advance Care Plan.
Effective January 1, 2021, Medicare increased payment for these services to $282 (it will get geographically adjusted) when provided in an office setting, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently covered these services via telehealth.
Use CPT code 99483 to bill for both in-person and telehealth services. In this article, we shared billing guidelines for cognitive assessment & care plan services in detail.
Basics of Cognitive Assessment
Providers can detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. Providers may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment.
If they detect cognitive impairment at a routine visit, they 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.
Detecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483.
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. Providers would typically spend 50 minutes face-to-face with the patient and independent historian to perform the cognitive assessment.
Billing Guidelines for Cognitive Assessment & Care Plan Services
Who can offer a cognitive assessment? Any clinician eligible to report evaluation and management (E/M) services can offer this service. Eligible providers include Physicians (MD and DO); Nurse practitioners; Clinical nurse specialists; and Physician assistants.
Where to perform the cognitive assessment? Providers can perform the assessment at any of these locations: Office or outpatient setting; Private residence; Care facility; Rest home, and Via telehealth.
Care plan: Providers will use information gathered during a cognitive assessment to help them create a written care plan. The care plan includes initial plans to address: Neuropsychiatric symptoms; Neurocognitive symptoms; Functional limitations; and 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.
Applicable CPT Codes
CPT G0438 (Initial AWV): Providers are required to check for cognitive impairment as part of the AWV.
CPT G0439 (Subsequent AWVs): Providers are required to check for cognitive impairment as part of subsequent AWVs.
CPT 99483 (Assessment of and care planning for patients with a cognitive impairment like dementia, including Alzheimer’s disease, at any stage of impairment): If providers detect a cognitive impairment during the AWV or other routine visit, they may perform a more detailed cognitive assessment and care plan. Applicable guidelines are as follows:
- Providers may bill this code separately from the AWV.
- If you choose to perform the AWV and the Cognitive Assessment & Care Plan Services in the same visit, add modifier 25 to the claim.
- Part B coinsurance and deductible would apply.
- This code has replaced the interim HCPCS code G0505.
- It includes Level 5 E/M service CPT code 99215 elements like Comprehensive history; Comprehensive exam; and High complexity medical decision-making.
- Providers can’t bill CPT code 99483 on the same day as these services:
- 90785 (Psych diagnostic evaluation complex interactive)
- 90791 (Psych diagnostic evaluation)
- 90792 (Psychiatric diagnostic evaluation with medical services)
- 96103 (Computer administered, computer-graded, psychologic assessment)
- 96120 (Computer administered neuropsychological testing)
- 96127 (Report behavioral assessments in children and adolescents)
- 99201– 99215 (Office/outpatient visits)
- 99324–99337 (Domiciliary rest home visits, new patient)
- 99341–99350 (Home visits)
- 99366–99368 (Team conference with the patient by health care professionals)
- 99497 (Advanced care plan 30 min)
- 99498 (Advanced care plan additional 30 min)
You will require a good understanding of the above-mentioned billing guidelines for your cognitive assessment claims to get paid accurately. Plus, your documentation must be appropriate to validate medical necessity.
If you need any help in medical billing and coding then MedicalBillersandCoders (MBC) can assist you. Our team has a good understanding of billing guidelines of cognitive assessment for Medicare and other private providers.
To know more about our cognitive assessment billing services, contact us at info@medicalbillersandcoders.com / 888-357-3226
FAQs:
1. What are the key components of a cognitive assessment for Medicare reimbursement?
A cognitive assessment must include a cognition-focused evaluation, identification of caregivers, and development or review of an Advance Care Plan. Providers typically spend about 50 minutes face-to-face with the patient and an independent historian.
2. Who is eligible to perform cognitive assessments under Medicare?
Any clinician eligible to report evaluation and management (E/M) services can perform these assessments, including MDs, DOs, nurse practitioners, clinical nurse specialists, and physician assistants.
3. Where can cognitive assessments be conducted?
Cognitive assessments can be performed in various settings, including offices, outpatient facilities, private residences, care facilities, and via telehealth.
4. What CPT codes are applicable for cognitive assessment and care planning?
Key CPT codes include:
- CPT G0438 for initial Annual Wellness Visits (AWV)
CPT G0439 for subsequent AWVs
CPT 99483 for detailed cognitive assessments and care plans
5. What documentation is necessary for the successful billing of cognitive assessment services?
Accurate documentation is essential to validate medical necessity for billing. Providers should ensure they follow billing guidelines and maintain comprehensive records to support claims.
