New codes for care planning of cognitive-impaired patients

Q: A family conference is one of the first services that we provide for our patients who have dementia and need additional help with activities of daily living, finances, driving, medications, and other services. Should we capture this service with a time-based E/M code, or is there another code that would work?

A: With our ever-growing geriatric population, it is important to note that the Center for Medicare and Medicaid Services (CMS) is adding new services to help manage their care. One of those services was just added January 1, 2018, and specifically focuses on the assessment of and care planning for patients with cognitive impairment.

It sounds as though this code might better describe the services that you are offering your patients. I’ve detailed the code below, a listing of the requirements included in the code descriptor, along with some additional information that you might find useful.

Medicare national reimbursement for CPT code 99483 is $178.92 for facility and $241.92 for non-facility. This is higher reimbursement than even that of 99205, which is $172.08 for facility and $210.60 for non-facility.

This shows that Medicare understands the importance of this type of service. Here are the elements required for this code:

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:
❚ Cognition-focused evaluation including a pertinent history and examination. While no specific elements are required for this code, the stipulation is that the focus is on the patient’s cognitive ability. So this should not be equated to E/M elements.
❚ Medical decision making of moderate or high complexity. These levels of medical decision making should equate to those levels spelled out in the E/M coding guidelines. This will be determined by the patient’s dementia severity and treatment and would also include depression, lack of functional ability and any co-morbidities.
❚ Functional assessment (e.g., basic and instrumental activities of daily living), including decision-making capacity.
❚ Use of standardized instruments for staging of dementia (e.g., 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 (e.g., 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. Advanced care planning has been a recent focus for Medicare, so your patients could well have a plan already in place.
❚ 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.
❚ Typically, 50 minutes are spent face-to face with the patient and/or family or caregiver. This service does not differentiate between new or established patient status.

Clinical Example

HPI Patient is a 75-year-old white male.

Seen today for a follow-up family conference regarding memory loss, mood, and lab results. Patient is accompanied by his wife, who provides additional information with patient’s permission.

Patient and family goals: He wants more independence.
Memory: Wife describes patient’s memory as variable. Wife first started to notice changes in patient’s memory about 4-5 months ago. Patient does repeat questions and stories, but he does not forget recent events or conversations. No word-finding issues reported. Patient takes 10 mg Aricept daily since November 2017.
Living environment: Patient lives with wife in a one-story home.
Support: Wife; patient’s 3 children are not involved in patient’s care. Patient’s wife is experiencing caregiver stress.
ADLs: Patient is independent in bathing, dressing, grooming, feeding, toileting, and ambulation.
Physical ambulation: Patient has a walker for home use, but does not use it consistently. A wheelchair is used away from home. Wife reported that patient had three falls.
Toileting: Patient has urinary incontinence and utilizes Depends for support. Takes Colace daily.
IADLs:
Finances: Wife manages money.
Meals: Wife prepares meals. Patient denies difficulty eating 2-3 meals/day. Some difficulty swallowing.
Medications: Patient’s wife has managed his medications since October 2017.
Driving: Patient stopped driving in October 2017.
Mood: Patient’s mood is described as labile and can go from pretty good to angry, irritable and being agitated. Patient’s recent office visit with PCP did mention anxiety and depression. Patient is taking Cymbalta 60, Klonopin 0.5 mg, 1/2- 1 tablet TID, and Remeron 7.5 mg at night.
Activities: Patient enjoys spending time with his wife. Patient likes to walk for exercise.
Sleep: Patient’s sleep is described as restless. Patient has sleep apnea, but does not use a CPAP, per wife. He declined a sleep study.
Appetite/weight: No overt concerns.
Vision: Patient uses reading glasses. Last exam March 2018.
Dentition: Has full set of dentures but does not use them. Last dental exam is unknown.
Hearing: Patient has some hearing loss. No hearing aids.
Pain: Bilateral shoulder pain which have both been replaced. On Cymbalata and uses OTC Ibuprofen for pain management. Will refer to PT.
Smoking: Quit 35 years ago.
Alcohol Intake: Denies current use.
Caffeine Intake: One cup of coffee per day.
Other chronic conditions: Arthritis; cancer; chronic kidney disease, stage 3, GFR 30-59 ml/min; COPD; Coronary artery disease; type 2 diabetes; GERD; hyperlipidemia; hypertension; lung disease.
Family history: Cancer in his maternal grandfather; Heart disease in his father and mother.
Review of systems:
General: Denies fevers, chills, weight stable with 4 pounds weight gain since the last visit
Cardiovascular: Denies chest pain, shortness of breath, edema
Pulmonary: Denies cough, difficulty breathing
Gastrointestinal: Denies abdominal pain, nausea, vomiting, black or tarry stool
Skin: Denies dryness, sores, other lesions
Psych: Denies depression, anxiety, hallucinations
Diagnostics: Mild neurocognitive disorder. Suggest using preset testing as baseline and that he be re-examined in 12-18 months.
PHQ-9 Test results show mild depression.