It could be financially worthwhile to delve more deeply into patients’ cognitive problems.
This article appears in the 5/25/2018 edition of Medical Economics
Many internists don’t perform a thorough cognitive evaluation. Instead, they often refer patients with suspected cognitive impairments to a neurologist, or they order a CT scan that may not actually be medically necessary. However, it could be financially worthwhile to delve more deeply into patients’ cognitive problems.
That’s because starting in January Medicare began paying physicians an average of $242 to perform a cognitive assessment and develop a care plan to address functional limitations as well as neurocognitive and neuropsychiatric symptoms. Physicians can report this service using CPT code 99483.
“I’m excited about this payment, because it allows us to sit down with our patients and address their needs in a meaningful and comprehensive way,” says Melissa Lucarelli, MD, FAAFP, primary care physician in Randolph, Wisc. and Medical Economics editorial board member.
CPT code 99483 was created to reimburse physicians when they go above and beyond a cursory cognitive assessment that’s typically included in the social history portion of an E/M visit or Medicare annual wellness exam, says Alan Lazaroff, MD, a member of the RVS Update Committee (RUC) and retired geriatrician in Denver, Colo. The RUC is a multi-specialty committee that recommends new codes and Relative Value Units to CMS. The code also describes what a comprehensive cognitive evaluation should entail.
A comprehensive cognitive evaluation isn’t only good for patients, it also helps physicians with their medical decision-making, says Lazaroff. “Once you know that a patient has cognitive impairment, it will influence how you approach every other medical issue they have,” he says. For example, patients with cognitive impairment may have difficulty following instructions or remembering symptoms. Working with a caregiver to adapt a treatment plan then becomes critical.
Evaluating and addressing cognitive impairments may also reduce costs-and benefit physicians under Medicare payment reform-by preventing hospitalizations for patients who might otherwise accidentally injure themselves or forget to take their medications, he adds.
Identify patients who qualify for the service
Experts agree that physicians will likely identify patients in one of two ways: They’ll suspect a cognitive impairment during a wellness exam or E/M visit, or a family member will call the practice because they’re concerned that their loved one has a problem.
If the patient is already in the office, physicians can explain why it’s important for them to come back for a comprehensive cognitive assessment, says Lucarelli. Explain what patients can expect (i.e., they’ll be in the office for an hour while staff perform various assessments) and why a visit dedicated to their cognitive status is an important part of keeping them safe and ensuring their needs are met, she says.
Physicians should remind patients that they’ll need to bring a family member or caregiver with them when they return for the assessment, says Margaret A. Noel, MD, founder of MemoryCare in Asheville, N.C., an organization that offers community-based care for memory-impaired individuals. CPT code 99483 requires the presence of an independent historian to provide information and help implement the care plan.
“Every person with a progressive dementia will eventually need a partner to assist in managing their health and safety,” says Noel. “Engaging a chosen trusted care partner early in the course of a cognitive disorder is really critical, and the cognitive assessment process supports doing this.”
It may be helpful to create an educational pamphlet about the cognitive assessment and remind patients that although Medicare will cover the service, they will owe a copayment, says Deb Santos, CPC, auditor at DoctorsManagement, a healthcare consulting firm in Temple, Texas.
If a family member calls out of concern, staff members should perform a brief phone screening to see whether their loved one has symptoms that are consistent with cognitive impairment, says Lazaroff. “You want to make sure that this is the right kind of patient for this evaluation because this is a lot of work, and you don’t want to do it on people who don’t need it,” he says. “You need a good solid reason to believe that there’s something going on cognitively with this patient.”
Divide and conquer the workload
CPT code 99483 requires an array of assessments and evaluations.
The good news is that physicians don’t need to perform all of the required elements, says Angela Jordan, CPC, senior managing consultant at Soerries Coding and Billing Institute, a practice management consulting company in Grain Valley, Mo.
For example, medical assistants, social workers, or non-physician providers can collect some of the data before the physician enters the exam room. Practices may also be able to send questionnaires and assessments to the caregiver through the EHR portal or mail these documents directly to the caregiver for completion prior to the appointment.
When the physician meets with the patient and caregiver, ideally they’ll have access to all of the assessments and evaluations and can focus on developing the care plan.
Lucarelli’s practice is developing a checklist to ensure that staff members perform certain tasks before she sees the patient (e.g., medication reconciliation, identify the caregiver, screen the patient for depression, and evaluate the safety of the patient’s home). The checklist, which is subsequently scanned into the EHR, requires Lucarelli and other physicians in the practice to circle a relevant diagnosis and provide a dated/timed signature.
“This won’t be our official chart note,” says Lucarelli. “It will be a supplemental sheet that’s basically our flow sheet. It will also help us with compliance if we ever get audited.”
Not only can other staff members help fulfill the required elements of the code, they can also do so over multiple visits that precede the actual care planning visit, says Noel, who began officially billing CPT code 99483 in early March. “It may be helpful to divide the components over routine E/M visits and then utilize those assessments to inform the more comprehensive care planning visit,” she says.
Document all required elements
EHR templates can ease the documentation requirements associated with CPT code 99483 that includes 10 specific elements. “Not all providers will be able to remember everything that’s required,” says Santos. “This is what happened with the Medicare Annual Wellness Visits. Something was always missing. The templates will help with the workflow and make sure they covered everything.”
Lucarelli is also developing a template that imports various safety screening tools and other assessments that already exist within her EHR. Likewise, MemoryCare has developed an EHR template for the final written care plan that helps guide physicians to document the necessary components associated with CPT code 99483. If practices don’t have the ability to create a template in the EHR, they can simply laminate a card that lists each of the 10 required elements, says Santos.
Though this may not be a high-volume service, it can make a significant difference in the lives of patients and their families, says Noel. “Patients and families need not only a timely diagnosis, they need a road map to help them through a very challenging illness.”
3 tips to avoid denialsConsider these three tips to avoid denials when reporting CPT code 99483.
Know when the service is appropriate. The cognitive assessment is intended to diagnose and evaluate chronic cognitive impairments. Don’t report CPT code 99483 for patients who are clinically unstable or acutely ill because the illness may transiently exacerbate the impairment, and physicians need to be able to identify a baseline cognitive capability for care planning purposes, says Alan Lazaroff, MD, retired geriatrician in Denver, Colo.
“The service is also not appropriate for individuals without cognitive disorders or for those who require briefer follow-up visits that are problem-focused,” says Margaret A. Noel, MD, founder of MemoryCare in Asheville, N.C.
Report the service only once every 180 days. However, remember to keep medical necessity in mind, says Deb Santos, CPC, auditor at DoctorsManagement in Temple, Texas. “If 180 days have passed, and nothing has changed-the care plan is the same, the caregiver is the same-then it may not be medically necessary,” she adds.
Angela Jordan, CPC, senior managing consultant at Soerries Coding and Billing Institute in Grain Valley, Mo., agrees, adding that payers will look for documentation indicating a new or substantial decline or an additional cognitive problem that requires a revised care plan.
Know what other CPT codes trigger a denial when billed with 99483. Per the 2018 CPT Manual, don’t report CPT code 99483 with any of the following services on the same date of service:
Advance care planning 99497-99498
Any outpatient E/M visits 99201-99205, 99211-99215, or 99241-99245
Brief emotional/behavioral assessment 96127
Complex chronic care management 99487 and 99489-99490
Domiciliary, rest home, or custodial care services 99324-99328 or 99334-99337
Home services 99341-99345 or 99347-99350
Interactive complex psychotherapy 90785
Medical team conferences 99366-99368
Medication therapy management 99605-99607
Neuropsychological testing 96120
Psychiatric diagnostic evaluation 90791-90792
Psychological testing 96103
Transitional care management 99495-99496