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Cognitive Assessment and Care Planning Services:

Alzheimer’s Association Expert Task Force Recommendations and Tools

for Implementation

1. Background and introduction to CPT® code 99483

The Alzheimer’s Association® has long advocated for Medicare reimbursement for services aimed at improving detection,

diagnosis, and care planning and coordination for patients with Alzheimer’s disease and related dementias (ADRD) and their

behavioral symptoms; review and reconciliation of medications; and assessment of the needs of the patient’s caregiver.

(See the CPT 2018 manual for full details.) These components are central to informing, designing and delivering a care

plan suitable for patients with cognitive impairment (Anonymous. Fed Register 2016).

The Alzheimer’s Association Expert Task Force provided information and suggestions on the content and use of Code

G0505 (now 99483) to the Centers for Medicare & Medicaid (CMS) during the comment phase (Alzheimer’s Association

Task Force, 2016), and reconvened in November 2016 to make recommendations about how to conduct the required

assessments. Its recommendations derive from a broad consensus about good clinical practice, informed by intervention

trials and emphasizing validated assessment tools that can be implemented in routine clinical care across the United States.

The multidisciplinary task force was comprised of geographically dispersed experts in the United States who provide

ongoing clinical care for individuals with ADRD and/or have published recognized works in the field.

deemed unnecessary for the patient’s condition. For these services, see the appropriate evaluation and management

(E/M) code. (American Medical Association, CPT 2018).

3. Who can provide this service?

Any practitioner eligible to report E/M services can provide this service. Eligible providers include physicians (MD and DO),

nurse practitioners, clinical nurse specialists, and physician assistants. Eligible practitioners must provide documentation

that supports a moderate-to-high level of complexity in medical decision making, as defined by E/M guidelines (with

application as appropriate of the usual “incident-to” rules, consistent with other E/M services) (Anonymous. Fed Register

2016). The provider must also document the detailed care plan developed as a result of each required element covered

by 99483.

Used with permission of the American Medical Association. (American Medical Association, 2018 Current Procedural

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• Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity;

• Use of standardized instruments for staging of dementia (eg, 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 (eg, 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;

The nine assessment elements of 99483 can be evaluated within the care planning visit or in one or more visits

that precede it, using appropriate billing codes (most often an E/M code). Patients with complex medical, behavioral,

psychosocial and/or caregiving needs may require a series of assessment visits, while those with well-defined or less

complex problems may be fully assessed during the care plan visit. Results of assessments conducted prior to the care

plan visit are allowed in care planning documentation provided they remain valid or are updated with any changes at

the time of care planning.

A single physician or other qualified health care professional should not report 99483 more than once every 180 days.

Many of the required assessment elements can be completed by appropriately trained members of the clinical team

working with the eligible provider. Assessments that require the direct participation of a knowledgeable care partner

or caregiver, such as a structured assessment of the patient’s functioning at home or a caregiver stress measure, may

through ongoing clinical contact with the patient and caregiver. Though all required elements must be represented, the

choice of assessment tools should be customized for differing clinician styles and practice composition, workflows and

overall clinical goals. For example, primary care providers and dementia specialists may prefer different tools.

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For several domains of care planning, simple, validated tools do not yet exist, and where they do, not all have been formally

tested for validity and uptake in actual primary care practices. In the table below, those that have been tested in primary

care are marked with an asterisk; those untested in primary care have either high face validity (e.g., Safety Assessment

checklist) or published validation data that support further use. Ideally, tools should be:

• Practical: Time and effort to complete them fit the primary care clinical setting.

• Parsimonious: Provide enough information to support a meaningful care plan.

• Scorable: Results depicted in a single number.

Cognition Mini-Cog

GPCOG

Short MoCA

≤ 3 min, validated in primary care

Patient/informant components

~ 5 min, needs testing in primary care

Function Katz (ADL), Lawton-Brody (IADL) Caregiver rated

Stage of cognitive impairment Dementia Severity Rating Scale Caregiver rated, correlates with

Clinical Dementia Rating

Decision-making 3-level rating: able to make own deci-

sions, not able, uncertain/needs more

evaluation

Global clinician judgment

NPI-Q

10 items

Caregiver Profile Checklist

Single-Item Stress Thermometer

PHQ-2

Ability/willingness to care, needs for

information, education, and support

Rapid identification of stress

Depression

Advance care planning End-of-Life Checklist Screen for preferences and legal needs

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Preparing the plan

The care plan should reflect a synthesis of the information acquired as part of the assessment. It should be written in

language that is easily understood, indicate who has responsibility for carrying out each recommended action step

and specify an initial follow-up schedule.

Some clinicians find it useful to organize the care plan into broad components, such as:

• Caregiver stress and support needs, including primary care counseling and, as indicated, referrals to community-

Though not required by 99483, a standardized care plan template customized to the provider or health care system

simplifies communication and tracking of patient care and outcomes over time. The written plan must be discussed

with and given to the patient and and/or family or caregiver; this face-to-face conversation must be documented in the

clinical note for all encounters reported using 99483. The care plan must be filed in the patient’s medical record where

it can be easily retrieved and updated. Sharing the plan with other providers caring for the patient, including clinicians,

care managers, caseworkers, and others who assist the patient and caregiver, both within and outside the primary care

the patient’s clinical or caregiving status. Medicare intermediaries may audit the frequency of use.

9. How does 99483 relate to Chronic Care Management (CPT 99490)?

CPT code 99490 is an appropriate service to use for monthly care management of a patient with dementia plus at least

one other chronic condition, after a cognitive impairment care plan has been developed and documented.

10. Identifying proper coding

CPT code 99483 was developed to provide reimbursement for 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. This service includes a thorough evaluation of medical and psychosocial factors, potentially

contributing to increased morbidity. 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

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Alzheimer’s Association Expert Task Force. Alzheimer’s Association Expert Task Force Consensus Statement on

CMS Proposed Billing Code for the Assessment and Care Planning for Individuals with Cognitive Impairment.

Release September 6, 2016. Available at: http://act.alz.org/site/DocServer/Taskforce_Consensus_Statement_FINAL.

pdf?docID=51841. Accessed November 29, 2016.

Soo Borson, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle,

WA; Memory Disorders Clinic and Dementia Health Services, University of Washington School of Medicine, Seattle, WA