In simple words: This code covers a doctor's visit to thoroughly assess a patient with memory problems or thinking difficulties. The doctor will talk to the patient and family, review medications, do tests to measure the patient's abilities, and create a plan for care. This visit usually takes about an hour.

This CPT code, 99483, encompasses a comprehensive assessment and care planning service for patients exhibiting cognitive impairment.It requires a cognition-focused evaluation with a detailed history and examination, moderate or high complexity medical decision-making, a functional assessment (including activities of daily living and decision-making capacity), utilization of standardized dementia staging instruments (e.g., FAST, CDR), medication reconciliation and review of high-risk medications, evaluation for neuropsychiatric and behavioral symptoms (including depression using standardized screening tools), safety evaluation (including home and driving), caregiver identification and assessment, advance care planning (development, revision, or review), and creation of a written care plan (including plans to address neuropsychiatric symptoms, cognitive symptoms, functional limitations, and referrals to community resources). The total time spent on the encounter date is typically 60 minutes.For services exceeding 75 minutes, code 99417 should be used instead.

Example 1: A 78-year-old patient presents with progressive memory loss and difficulty with daily tasks. The physician performs a comprehensive cognitive assessment using standardized tools, reviews the patient's medications, identifies potential safety hazards in the home, and develops a care plan including referrals to occupational therapy and a support group for caregivers., A 65-year-old patient with a history of stroke experiences cognitive decline and behavioral changes. The physician conducts a detailed assessment, identifies depression as a contributing factor, initiates treatment for depression, and creates a care plan involving medication management, counseling, and home safety modifications., An 85-year-old patient in a nursing home shows signs of worsening dementia.The physician conducts the assessment, reviews the current care plan, updates it based on the patient's current status and makes referrals for palliative care.

Detailed history (including cognitive symptoms, functional abilities, medication list, caregiver information, and social support), results from standardized cognitive assessment tools (e.g., MMSE, MoCA), functional assessment (ADLs and IADLs), medication reconciliation, safety assessment (home and driving), caregiver assessment, advance care plan documentation, and a written care plan outlining treatment goals, referrals, and support services. Documentation should reflect the time spent with the patient and/or caregiver.

** This service should only be reported once every 180 days for the same patient by the same provider.The use of standardized instruments for assessment is crucial for accurate coding.