Cognitive Assessment
Table of Contents
Billing Codes
- 99483: 60 minute face-to-face
Billing Information
- Cognitive assessment is required to check for cognitive impairment as part of the annual wellness visit. (G0438, G0439)
Documentation
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, 60 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 FAST and 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 ACP and any palliative care needs
Related Content
- Cognitive Assessment and Care Plan Services CPT Code 99483
- Cognitive Assessment & Care Plan Services
- Care Management
Reviewed 10/12/2023