Detecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). You can also detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. You may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment.

If you detect cognitive impairment at an AWV or other routine visit, you may perform a more detailed cognitive assessment and develop a care plan during a separate visit. This additional evaluation may be helpful to diagnose a person with dementia, such as Alzheimer’s disease, and to identify treatable causes or co-occurring conditions such as depression or anxiety.

Any clinician eligible to report evaluation and management (E/M) services can offer this service. Eligible providers include:

• Physicians (MD and DO)

• Nurse practitioners

• Clinical nurse specialists

• Physician assistants

You can perform the assessment at any of these locations:

• Office or outpatient setting

• Private residence

• Care facility

• Rest home

• Via telehealth

The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483. An independent historian can be a parent, spouse, guardian, or other individuals who provide patient history when a patient isn’t able to provide complete or reliable medical history.

Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment:

• Examine the patient with a focus on observing cognition

• Record and review the patient’s history, reports, and records

• Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity

• Use standardized instruments for the staging of dementia-like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR)

• Reconcile and review for high-risk medications, if applicable

• Use standardized screening instruments to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety

• Conduct a safety evaluation for home and motor vehicle operation

• Identify social supports including how much caregivers know and are willing to provide care

• Address Advance Care Planning and any palliative care needs