EM Coding Alert

Understand all the strings attached to 99483.

There are so many rules surrounding 99483 (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: …) that it’s a wonder anyone can use it correctly.

Well, E/M Coding Alert found just such a person. Susan Marie Roelant, CPC, CPCO, CEMC, CPMA provided a masterclass in cognitive assessment coding when she gave her presentation “Cognitive Assessments and Psychological/Neuropsychological Testing Codes” during AAPC’s virtual HEALTHCON 2020.

Here are Roelant’s words of wisdom about using this tricky E/M code.

Check Out This 99483 Rundown

Roelant ran down the basics of a 99483 cognitive assessment thusly:

• Any place of service can report cognitive assessment codes.
• The provider must document 10 elements for cognitive assessment to be paid.
• Patients often include Alzheimer’s and dementia patients.
• Any clinician who can report an E/M code can report this service.
• Ancillary staff can collect some of the info on these 10 documentation requirements, but the performing provider must review their collection.
• Typically 50 minutes are spent face to face with patient/caregiver.
• Many services are elements of the cognitive assessment, and you can’t report them on same day as 99483. This includes evaluation and management (E/M) services, psychological testing, medication therapy management, etc.

Patient eligibility: Patients who receive 99483 services can be new or established, Roelant relayed.

Note Multidimensional Cognitive Assessment Before Choosing 99483

The cognitive assessment that qualifies for 99483 must be a “multidimensional assessment that includes cognition, function, and safety,” explained Roelant.

This assessment must include evaluation of neuropsychiatric and behavioral symptoms and meet 10 specific documentation requirements. Do not report 99483 if the provider doesn’t address and document any of the 10 elements, warned Roelant; you need them all to correctly report the code.

Any healthcare clinician who is eligible to report an E/M service can report 99483. Incident-to rules are in effect for Medicare carriers, and the rules apply to the place of service (POS). For instance, Medicare doesn’t allow incident-to billing in the skilled or long-term care setting, Roelant said. Ancillary staff can collect some of the required information, but the performing provider must review the clinician’s notes and add to the final plan, if necessary.

Documentation

Here is the remainder of the 99483 code descriptor, which lists the 10 elements the exam must contain in order to report 99483:

1. Cognition-focused evaluation including a pertinent history and examination;
2. Medical decision making of moderate or high complexity;
3. Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity;
4. Use of standardized instruments for staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]);
5. Medication reconciliation and review for high-risk medications;
6. Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s);
7. Evaluation of safety (eg, home), including motor vehicle operation;
8. Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks;
9. Development, updating or revision, or review of an Advance Care Plan;
10. 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 (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.

Remember: The performing provider must perform and document all 10 of these elements, or your 99483 claim likely won’t be accepted.