What is Cognitive impairment?
According to the Center for Disease Control (CDC):
Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. With mild impairment, people may begin to notice changes in cognitive functions, but still be able to do their everyday activities. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently.[i]
Cognitive impairment not only impacts victims of these symptoms, but also those around them. Patients with Alzheimer’s disease and other dementia related diseases experience cognitive impairment resulting in frequent doctor visits and hospital stays. Those experiencing impairment will likely need an assessment. According to the Alzheimer’s Association, “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. Do not report cognitive assessment and care plan services if any of the required elements are not performed or are deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management (E/M) code”[ii]
How is it Billed?
In January 2018, the American Medical Association added Current Procedural Terminology (CPT) code 99483. According to Medicare, CPT 99483, replaced HCPCS G0505. The description for CPT 99483 is as follows[iii]:
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, with all of the following required elements:
- Cognition-focused evaluation including a pertinent history and examination,
- Medical decision making of moderate or high complexity,
- Functional assessment (e.g., basic, and instrumental activities of daily living), including decision-making capacity,
- Use of standardized instruments for staging of dementia (e.g., 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 (e.g., 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, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (e.g., 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.
What to look for?
- According to the Alzheimer’s Associationii, physicians, nurse practitioners, clinical nurse specialists and physician assistants may perform this assessment, however, review any specialists billing significantly more than their peers or who typically bill this service at all. Don’t forget to check their subspecialties.
- Ensure all the elements of the service are performed, otherwise an E/M may be the more appropriate service.
- Look at the percentage of a provider’s patient population receiving this service and how often (the Alzheimer’s Association states the service should be reported more than once every 180 days)ii.
- Review the diagnoses to see if the correspond to the service and are deemed appropriate.
- Unbundling this assessment from other services on the same day.
An example of the type of activity monitored by Healthcare Fraud Shield is in the following alert:
[2547-01] – UNBUNDLING, COGNITIVE ASSESSMENT AND CARE PLAN SERVICES: This Alert identifies providers billing cognitive assessment and care plan services in conjunction with E/M services, psychiatric diagnostic procedures, brief emotional/behavioral assessments, psychological or neuropsychological test administrations, health risk assessment administrations, or medication therapy management services for the same patient on the same day, as this is considered unbundling.
References:
[i] https://www.cdc.gov/aging/pdf/cognitive_impairment/cogimp_poilicy_final.pdf
[ii] https://www.alz.org/careplanning/downloads/cms-consensus.pdf
[iii] https://www.aapc.com/codes/cpt-codes/99483
If you have any questions or comments, please reach out to [email protected].