LCD L39266: Cognitive Assessment and Care Plan Service

This is a coverage policy for Cognitive Assessment and Care Planning.

Cognitive impairment may be considered and be of initial concern to a practitioner within the context of 1 of these scenarios:

• Detection as a required element of Medicare’s Annual Wellness Visit (AWV), or

• As part of a routine visit with the patient based on direct observation or via a brief cognitive test, or

• Upon consideration of information from the patient, family, friends, caregivers or others.

Medicare covers a separate visit in order to perform a more detailed cognitive assessment and develop a thorough care plan.

Any provider eligible to report evaluation and management services can provide this service. Eligible providers include: physicians (MD or DO), nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) or physician assistants (PA).

The service can be provided in these locations: office or outpatient setting, private residence, care facility, rest home, or via telehealth.

The cognitive assessment service includes a detailed history and exam. An independent historian (parent, spouse, guardian or other individual) must be present to provide history that the patient may not be able to completely and reliably provide.

The following elements are central to informing, designing and delivering a care plan suitable for patients with cognitive impairment. These elements must be documented for purposes of a complete cognitive assessment.

• Cognition-focused evaluation, including a pertinent history and examination;

• Medical decision making of moderate or high complexity;

• Functional assessment (e.g., Basic and Instrumental Activities of Daily Living), including decision-making capacity;

• Use of standardized instruments to stage 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 and including use of standardized instruments;

• Evaluation of safety, at home and otherwise, including motor vehicle operation, if applicable;

• Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports and willingness of caregiver to take on caregiving tasks;

• Development, with periodic updating/revision/review of an Advance Care Plan;

• Creation of a written care plan which includes initial plans to address any neuropsychiatric symptoms, neurocognitive symptoms, functional limitations, and referral to community resources as needed. This care plan must be documented as having been shared with the patient and/or caregiver at the time of initial education and support.

Clear documentation noting the performance of each and every 1 of these service components must be clearly identifiable within the medical record. The companion billing and coding article to this local coverage determination (LCD) should be referenced for further detail concerning documentation expectations.

Several of these service components require the use of standardized validated tools for appropriate measurement. Such tools offer a basic framework on which to build a nuanced clinical understanding of care needs via ongoing clinical contact with the patient and caregiver. All utilized assessment tools must demonstrate standardization, validation and be recognized as credible by reputable national specialty organizations. Palmetto GBA reserves the right to review the accuracy, reliability, efficacy, and general credibility of assessment measurement tools utilized and will amend the billing and coding article as needed. Please see the companion billing and coding article to this policy for details related to allowable assessment tool use and accompanying documentation. These requirements, of course, do not preclude the use of additional assessment methods as desired by individual practitioners.

Due to the importance of accurate assessment for every beneficiary, documentation of all utilized assessment tool results must be present in the medical record. The instrument used should be named and findings should be summarized. The full instrument raw scoring and results for each utilized scoring tool must be available for A/B Medicare Administrative Contractor review if requested.

The care plan portion of this service must include, but is not limited to, the following elements:

• Neuropsychiatric symptoms must be addressed (even their absence) with a plan for management.

• Neurocognitive symptoms must be addressed (even their absence) with a plan for management.

• Functional limitations must be addressed with a plan for management.

• Any options for needed community services (such as rehabilitation, adult day programs, support groups) must be documented as having been shared with the patient and/or caregiver.

The absence of documentation regarding any required element in the provision of this service and/or within the written care plan represents incomplete service provision.

Many of the needed service elements for cognitive assessment and care planning (such as psychosocial needs, caregiver identification, driving and other safety issues and work on community resource referrals) could and perhaps should be performed by ancillary staff members. The service must be fully documented including all portions of the service initiated and completed by ancillary staff members or contracted parties incident to the practitioner completing the actual written care plan.

Experts have noted that care planning for individuals with dementia is an ongoing process and that a formal update to a care plan should occur at least once per year.

At the current time the potential benefits of a care plan are felt to extend to beneficiaries with any degree of cognitive impairment. Nevertheless, reasonable and necessary conditions for the provision of this service must be clear upon review of the medical record. Thus, all elements of the service, complete assessments, accurate diagnoses, adequate invested time, and comprehensive work toward the well-being of the beneficiary must be documented. This effort should be obvious and commensurate with the valuation of the work associated with this overall service. This coverage policy will be monitored for effectiveness and overall benefit to individuals in various disease stages. Eligibility for coverage may be revised in the future with appropriate notice and comment opportunities.

Approximately half of all people with various dementia conditions (including Alzheimer’s) have been diagnosed and less than half of those who have been diagnosed (or their caregivers) are actually aware of the diagnosis. While there are many reasons for this scenario, 2 have been frequently noted by Alzheimer’s experts. One is a sense of futility within the medical community and the second has been the lack of reimbursed time for handling the multi-faceted aspects of these conditions. Pharmacologic approaches are sadly lacking, but there are still many approaches that can be utilized to improve the quality of life and safety for such patients when focus is brought to appropriate diagnosis and care planning. However, such care plans must be of high quality. A “pro-forma set of check boxes” as an approach to a high-quality care plan is not representative of the type of assessment and care planning that will best serve this demographic of the population with cognitive impairments. 1

It has been suggested by the Alzheimer’s Association’s Expert Taskforce 1 (the Task Force) that a multi-disciplinary approach to the cognitive assessment and care plan service would be best. Thorough care plans can be helpful on many levels. One analysis showed care planning for individuals newly diagnosed with Alzheimer’s and other dementias would save Medicare $692 million over 10 years. 1 According to the most recent Global Burden of Disease classification system, Alzheimer disease rose from the 12th most burdensome disease or injury in the United States (U.S.) in 1990 to the 6th in 2016 in terms of disability-adjusted life-years. It has been projected that by 2050 Alzheimer dementia will affect 13.8 million U.S. residents . 2

The Task Force clarified its belief that a static one-time care plan is inadequate for proper care of these patient with a progressive disease that may span years. Needs, life circumstances, living arrangements, behaviors, and caregivers can be expected to change. Frequency for this cognitive assessment and care planning service was recommended at no less than once per year. While the full cognitive assessment and care plan service cannot be provided more than once every 180 days by any single provider, CMS has been clear that adjustments to the care plan can be made at any interval per the use of appropriate evaluation and management codes or chronic care management codes, as applicable.

The expert Task Force stated that the development and existence of a care plan for purposes of cognitive impairment should be readily identifiable.