Dementia covers a group of conditions that cause loss of cognitive functioning. The Centers for Disease Control and Prevention (CDC) describes dementia as a “general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities”. Increasing age is the strongest risk factor for dementia, which includes Alzheimer’s disease. Though the condition is more common in people over the age of 65, it can begin even in people in their 30s, 40s, or 50s. Medicare covers inpatient hospital care as well as physicians’ fees and other medical items for people with dementia who are age 65 or older. Practitioners can outsource medical billing to an expert to ensure that claims are submitted to using the correct and modifiers. Following Medicare billing guidelines and avoiding under-coding and over-coding is essential to prevent denials.
Signs and Symptoms of Dementia
According to the Population Research Bureau (PRB), about 3% of adults ages 70 to 74 had dementia in 2019, compared with 22% of adults ages 85 to 89 and 33% of adults ages 90 and older. Women have a higher risk of dementia than men.
While damage or loss of neurons is a normal part of aging, people with dementia experience extensive changes in their nerves and brain tissue. Conditions that damage the brain cells (neurons) or the connections between brain cells cause dementia. The signs and symptoms can vary based on the part of the brain that is damaged. Dementia involves both cognitive changes and psychological changes that may include:
- Decline in memory, poor judgment, and confusion
- Difficulty understanding and communicating, and expressing thoughts, or reading and writing
- Difficulty with routine daily tasks
- Getting lost in a familiar neighborhood due to decline in visual and spatial abilities
- Repeating questions
- Impaired reasoning or difficulty with complex tasks
- Losing interest in normal daily activities or events
- Hallucinating or paranoia
- Impulsive behavior
- Personality changes
- Problems with movement, coordination and balance
Dementia is not a specific disease, but several diseases can cause dementia. Alzheimer’s disease is the most common cause of a progressive dementia in older adults. Other causes include but are not limited to: strokes, Parkinson’s disease, dementia with Lewy bodies, frontotemporal dementia, Huntington’s disease, severe head injury and genetic factors.
Age, family history, and genetics are biggest risk factors for these chronic conditions. Although there is no proven way to prevent dementia, it is generally believed that leading a healthy lifestyle could help reduce risk factors linked to these diseases.
Types of Dementia
- Alzheimer’s disease: This is the most common cause of dementia diagnosis in older adults. It is caused by changes in the brain, including abnormal buildups of proteins. The brains of people with Alzheimer’s disease have plaques and fibrous tangles, which are clumps of certain proteins. Experts think that these clumps or damage healthy neurons and the fibers connecting them.
- Vascular dementia: This a form of dementia develops when vessels that supply blood to the brain get damaged, interrupting the flow of blood and oxygen to the brain. Damaged blood vessels can cause strokes or affect the fibers in the white matter found in the deeper tissues of the brain. Symptoms of vascular dementia include problem-solving issues, slowed thinking, and loss of concentration and organization.
- Frontotemporal dementia: This rare form of dementia affects people under 60. It is associated with the breakdown of nerve cells and their connections in the frontal and temporal lobes of the brain, and causes changes in personality, thinking, reasoning, behavior and language.
- Lewy body dementia (LBD): Lewy bodies are abnormal balloon like clumps of protein found in people with LBD, Alzheimer’s disease and Parkinson’s disease. This common symptoms of this progressive type of dementia include visual hallucinations, problems with movement, focus, and attention, tremors, and rigidity.
- Mixed dementia: Autopsy studies of older patients with dementia have found that many had a combination of several conditions such as such as Alzheimer’s disease, vascular dementia and Lewy body dementia.
Medicare Coverage for Dementia Care
Medicare provides coverage for cognitive assessment & care plan for people with Alzheimer’s or dementia who are age 65 or older. This includes inpatient hospital care and some of the physician fees and other medical items, and prescription drugs.
- Medicare covers up to 100 days of skilled nursing home care under limited circumstances.
- Medicare covers hospice care delivered in the home, a nursing care community or an inpatient hospice setting for people with dementia who are medically assessed as being near the end of life.
- Custodial long-term nursing home care is not covered.
- Deductibles, copayments, and coinsurance differ between traditional Medicare and Medicare Advantage.
Parts of Medicare that cover dementia care:
- Medicare Part A: covers inpatient stays at hospitals and SNFs and some home health care and hospice care.
- Medicare Part B: covers physician’s services, medical equipment, and services necessary to diagnose or treat a medical condition.
- Medicare Advantage: covers the basic benefits in Parts A and B and may offer additional benefits like dental, vision, and prescription drug coverage (Part D).
- Medicare Part D: covers medications prescribed for dementia.
- Medicare Supplement (Medigap): helps pay for costs such as coinsurance, copays, and deductibles that are not covered by Parts A and B.
Billing for Dementia Care
Here are the key points on billing Medicare for cognitive assessment and care plan services:
- If a patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit for conducting a more thorough evaluation of the patient’s cognitive function and developing a care plan. Applies to patients that:
- Have a diagnosis of Alzheimer’s, other dementias, or mild cognitive impairment
- Have been determined as cognitively impaired by the clinician
- Use CPT code 99483 to bill this service: CPT 99483 Evaluation, Treatment, and Care Planning for Cognitive Impairment.
- 99483 may be billed separately from the Annual Wellness Visit (AWV).
- If the AWV and the Cognitive Assessment & Care Plan Services are provided in the same visit, add modifier 25 to the claim.
- Use the appropriate ICD-10 code related to dementia or mild cognitive impairment along with code 99483.
- Providers eligible to report evaluation and management (E/M) services can offer this service and include physicians (MD and DO), nurse practitioners, clinical nurse specialists and physician assistants.
- The locations where cognitive assessment can be performed are: office or outpatient setting, private residence, care facility, rest home, and via telehealth.
- Clinicians may bill care planning services under 99483 once every 180 days
- When using 99483, it is important to know the restrictions. For example, some service components under 99483 overlap with advance care planning. 99483 cannot be reported with 99201 – 99215 (outpatient new and established patients) and some other services
- Billing 99483 requires a documented care plan
- ICD-10 codes to use with CPT 99483 Evaluation, Treatment, and Care Planning for Cognitive Impairment include:
G30.0 Dementia Alzheimer’s disease with early onset
G30.1 Dementia Alzheimer’s disease with late onset
G30.9 Dementia Alzheimer’s disease, unspecified
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
G31.01 Pick’s disease G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
G31.84 Mild cognitive impairment, so stated
G31.85 Corticobasal degeneration
New ICD-10 Codes for Dementia in 2023
The FY2023 ICD-10 update includes 83 new codes in Chapter 5 (Mental, Behavioral and Neurodevelopmental disorders (F01-F99) to further capture dementia symptoms and severity. A few if the new dementia codes in this section are:
F02.811 Dementia in other diseases classified elsewhere, unspecified severity, with agitation
F02.A11 Dementia in other diseases classified elsewhere, mild, with agitation
F02.B11 Dementia in other diseases classified elsewhere, moderate, with agitation
F02.C11 Dementia in other diseases classified elsewhere, severe, with agitation
As of January 1, 2022, Medicare pays approximately $283 (may be geographically adjusted) for these services when provided in an office setting (www.cms.gov). CPT 99483 has been added to the Medicare telehealth list.
With new codes and updated guidelines, billing for dementia care can be challenging. Outsourced medical billing and coding services are a practical option to ensure accurate billing. Experienced service providers have expert medical coders and billers who will work with the physician to assign the right codes and submit accurate claims so that the practice receives timely, full reimbursement.