Learn the 2 key components of billing for CPT code 99483

Physicians routinely assess their cognitively impaired patients using cognitive screening tools, labs and diagnostics, review of relevant personal and medical history, and input from family members and caregivers. These assessments are followed by counseling and recommendations for support and community resources.

With the availability of Current Procedural Terminology (CPT®) code 99483, the physician can better organize these aspects of patient care and receive significant reimbursement when the requirements of the code are met.

Detection of cognitive impairment establishes medical necessity for providing a care plan. CPT 99483 consists of two key components:

Key component #1

The first is a visit with the identified patient and a family member or caregiver. This visit must include medical decision making of moderate or high complexity (defined by the E/M guidelines) and include documentation in the patient medical record with the following components:

    1. Cognition-focused evaluation including a pertinent history and exam. Use of standardized instruments to stage dementia.
    2. Functional assessment including decision-making capacity.
    3. Medication reconciliation and review for high-risk medications, if applicable.
    4. Evaluation for neuropsychiatric and behavioral symptoms, including depression and the use of standardized instrument(s).
    5. Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and willingness of caregiver to take on caregiving tasks.
    6. Evaluation of safety, including motor vehicle operation, if applicable.
    7. Address palliative care needs, if applicable and consistent with beneficiary preference.

Key component #2

Following collection and synthesis of the above data, the physician then must create a care plan, including initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed. The care plan is shared with the patient and/or caregiver with initial education and support.

In our next post, we will detail how the adoption of BrainCheck Care™, a digital decision support and cognitive care planning platform, can help the physician provide a care plan that meets regulatory requirements and streamlines collection of relevant clinical data and construction of the plan.