Cognitive Assessment and Care Plan (CACP) - JE Part B

If you see signs and or symptoms, indicating cognitive concerns, in your patient during an Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE), or any Evaluation and Management Exam (E&M) there is an additional visit they may qualify for - 99483.

• Added these services to definition of primary care services in Medicare Shared Savings Program
• Permanently covered via telehealth (same CPT code)

Eligible Providers

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

Place of Service

You can perform the assessment at any of these locations:

• Office or outpatient setting
• Private residence
• Care facility
• Rest home
• Via telehealth

Components

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 individual who provides 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 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

Written Care Plan Creation

You'll use information gathered during a cognitive assessment to help you create a written care plan. The care plan includes initial plans to address:

• Neuropsychiatric symptoms
• Neurocognitive symptoms
• Functional limitations
• Referral to community resources as needed (for example, rehabilitation services, adult day programs, support groups) shared with the patient or caregiver with initial education and support

Billing

Monoclonal Antibody Coverage

Coverage Criteria, effective April 7, 2022:

1. Monoclonal antibodies directed against amyloid, approved by the FDA for treatment of Alzheimer's disease (AD) based upon evidence of efficacy from a change in a surrogate endpoint (amyloid reduction) considered as reasonably likely to predict clinical benefit may be covered in a randomized controlled trial conducted under an investigation new drug application. (NID).
2. Monoclonal antibodies directed against amyloid, approved by the FDA for treatment of Alzheimer's disease (AD) based upon evidence of efficacy from a direct measure of clinical benefit may be considered as reasonably likely to predict clinical benefit may be covered in a randomized controlled trial conducted under an investigation new drug application. (NID).
3. Medicare will cover drugs with FDA approval when a physician and clinical team participates in the collection of evidence about how these drug work in the real world - the Registry
   • Leqembi (J0174) and Kisunla (J0175)
     • Temporary codes for future drugs: J3490, J3590, or C9399
   • ICD-10: Z00.6
   • Additional codes: G30.0, G30.1, G30.8, G30.9, G31.84
   • Modifier: Q0 or Q1
   • Condition (Institutional only) code: 30
   • Eight digit National Clinical Trial (NCT) number 99999999
   • Type of Bill (Institutional): 012X, 013X, or 085X
4. For CMS-approved studies, the protocol, including the analysis plan, must include:
   1. A study population whose diversity is representative of the national population with mild cognitive impairment (MCI) due to AD or mild AD dementia
   2. A neurocognitive evaluation and instruments used to assess cognition function for the clinical diagnosis of MCI due to AD or mild AD dementia for study enrollment and outcomes assessment
   3. A description of:
      1. Multidisciplinary dementia team and optimal medical management
      2. Study sites with clinical expertise and infrastructure
5. CMS approved studies of amtiamyloid mAbs approved by FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address the following questions:
   1. Does the antiamyloid meaningfully improve health outcomes?
   2. Do benefits and harms such as brain hemorrhage and edema, associated with use of the antiamyloid mAb, depend on characteristics of patients, treating clinicians, and settings?
   3. How do the benefits and harms change over time?
6. Review NCD 200.3 for more information on standards of scientific integrity identified by the Agency for Healthcare Research and Quality (AHRQ)

Resources

• CMS Change Request (CR) 12649
• CMS Cognitive Assessment & Care Plan Services
• CMS Cognitive Assessment Provider Letter for Posting
• CMS NCD - Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD) (200.3)
• CMS Prospective Study on Anti-Amyloid-ß Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease Coverage of Evidence Development (The Anti-Aß mAb CED Study)
• CMS Report to Congress for CACP Provider Outreach Campaign
• CMS YouTube video Medicare Coverage and Payment of Cognitive Assessment & Care Plan Services
• National Institute on Aging Alzheimer's and Related Dementia Resources for Professionals
• Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease CED Study Registry