<aside> ✅

Supported Line of Business: Medicare + Commercial

</aside>

Comprehensive cognitive assessment and individualized care plan for patients presenting with signs of cognitive impairment — billed under a dedicated CMS pathway separate from standard E/M services.

Overview

Cognitive Assessments are a structured clinical assessment and care planning visit for patients with cognitive impairment. It is not a neuropsychological testing code — it is an element-based clinical service that requires completion of 10 specific documentation components and production of a written care plan.

Cognitive Assessments are not standard evaluation and management (E/M) visits. The key distinction: Cognitive Assessments require completion of 10 required elements; they’re not billable based on medical decision making (MDM) or total time alone.

Dimension Cognitive Assessment (99483) Standard E/M (99202–99215)
Billing code 99483 99202–99215
Level driver Completion of all 10 required elements MDM or time
Independent historian Required Not required
Written care plan Required Not required
Frequency limit Once per 180 days Standard E/M frequency rules

Consent Requirements

When to capture: Prior to the first Bridge visit. The consent to treat must be documented in the chart and confirmed in the submitted note:

👋 Work with your Bridge contact to confirm the consent has been configured before scheduling Bridge patients.

Service Frequency & Scope

Category Details
Payer eligibility Supported: Medicare Advantage (MA) and Commercial.
Provider types MD/DO, NP, PA within scope of practice.
Service frequency Once per 180 days per patient per billing provider. The clock resets from the date of the last billed 99483 — this is not a calendar-year limit.
Time expectation ~50 minutes of face-to-face time considered reasonable. The code is element-based, not strictly time-based.
Independent historian Required. Document historian name, relationship to patient, and participation method (in-person, phone, or video). If unavailable, document the reason.
Telehealth delivery Synchronous audio-video required. The historian may participate remotely if documented.

The 10 Required Elements

⚠️ All 10 elements must be documented with patient-specific findings. A missing element means the service cannot be billed as CPT 99483. Templated checkbox attestations without individualized content are insufficient.

# Element What to Document
1 Cognition-focused evaluation Structured history + exam: orientation, attention, memory, language, executive function, and behavior. A brief screening score alone is insufficient.
2 Medical decision making — moderate (L4) or high complexity (L5) Differential diagnoses, data reviewed, and risk level per AMA MDM guidelines.
3 Functional assessment (Basic + Instrumental ADLs) Basic ADLs (bathing, dressing, feeding, toileting, transferring) and Instrumental ADLs (finances, medications, driving, cooking). Document decision-making capacity.
4 Standardized dementia staging instrument Document instrument name, score, and date. Accepted: FAST, CDR, GDS. MoCA and MMSE alone do not satisfy this element.
5 Medication reconciliation Full medication list reviewed. Flag high-risk meds: anticholinergics, benzodiazepines, opioids, antipsychotics, sedative-hypnotics. Document changes and rationale.
6 Neuropsychiatric & behavioral symptom screening (including depression) Use a named, scored instrument: NPI-Q, BEHAV5+, or PHQ-2. Document instrument name, score, and date. Observation notes without a validated instrument are insufficient.
7 Safety assessment Document home safety (fall risk, wandering, hazards) and motor vehicle operation safety. Record findings and actions taken.
8 Community resource identification & referral Document resources discussed or referrals made: Area Agency on Aging, Alzheimer's Association, caregiver respite, adult day programs, legal/financial planning.
9 Caregiver assessment Document caregiver knowledge of diagnosis, needs, and stress level. Include any referrals made.
10 Advance care plan Document development, update, or review. Record patient's healthcare preferences, goals of care, and who holds decision-making authority if patient lacks capacity.