Cognitive Assessment & Care Plan Services - CPT 99483 [last edit 1-30-2022]
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.
What’s Included in a Cognitive Assessment?
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.
Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment:
- Examine the patient with a focus on observing cognition
- Record and review the patient’s history, reports, and records
- Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity
- Use standardized instruments for staging of dementia like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR)
- Reconcile and review for high-risk medications, if applicable
- Use standardized screening instruments to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety
- Conduct a safety evaluation for home and motor vehicle operation
- Identify social supports including how much caregivers know and are willing to provide care
- Address Advance Care Planning and any palliative care needs
TCM Services Requirements [last edit 1-30-2022]
The 30-day TCM period begins on a patient’s inpatient discharge date and continues for the next 29 days ("inpatient"; "SNF"; not ED, not urgent care).
TCM services begin the day of discharge from 1 of these inpatient or partial hospitalization settings:
- Inpatient Acute Care Hospital
- Inpatient Psychiatric Hospital
- Long-Term Care Hospital
- Skilled Nursing Facility
- Inpatient Rehabilitation Facility
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a Community Mental Health Center
After inpatient discharge, the patient must return to their community setting.
These could include:
- Nursing home
- Assisted living facility
99495 (visit in 14 days)/99496 (visit in 7 days):
- Communication (direct contact, telephone, electronic) with the patient and /or caregiver within 2 business days of discharge
- Medical decision making of at least moderate complexity during the service period
- Face-to-face visit, within 14 or 7 calendar days of discharge (depends on visit and timing from discharge)