_______________________________ Alzheimer Disease and Dementias: Early Detection and Care Planning
COMMONLY USED DIAGNOSTIC CODES
Code
Description
G31.09 G31.83 G31.84 G30.0 G30.1 G30.9 F03.90 F03.91 F01.50 F01.51 F02.80 F02.81 F03.91
Frontotemporal Dementia Dementia with Lewy Bodies Mild Cognitive Impairment
Alzheimer’s Disease with Early Onset Alzheimer’s Disease with Late Onset Alzheimer’s Disease Unspecified
Unspecified Dementia without Behavioral Disturbance Unspecified Dementia with Behavioral Disturbance Vascular Dementia without Behavioral Disturbances Vascular Dementia with Behavioral Disturbances
Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbances Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbances
Unspecified Dementia with Behavioral Disturbances
Source: Compiled by Author
Table 5
More information can be found on billing codes specific to cognitive impairment by the Alzheimer’s Association in their Cognitive Impairment Care Planning Toolkit found at https:// www.alz.org/media/Documents/Cognitive-Impairment-Care- Planning-Toolkit_1.pdf. DOCUMENTATION Proper documentation is crucial for billing cognitive assess- ments accurately. It is also important to note that the total time spent on the assessment and care planning must meet the minimum requirements for the chosen billing code (typically 50 minutes for CPT code 99483). When using CPT Code 99483, healthcare providers should conduct a detailed assess- ment and document the assessment findings to include test scores and interpretations, clinical observations, and patient and caregiver reports. The detailed assessment should include: • Cognitive assessment using standardized tools (e.g., MMSE, Montreal Cognitive Assessment): Detailed evaluation of the patient’s cognitive function, including memory, attention, language, and executive function • Functional assessment: Evaluation of the patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) • Medication review: Comprehensive review of all medi- cations the patient is taking, including prescription drugs, over-the-counter medications, and supplements • Safety evaluation: Assessment of the patient’s safety, including risks of falls, wandering, and other hazards • Caregiver assessment: Evaluation of the caregiver’s needs and the impact of caregiving on their health and well-being
CARE PLANNING Care planning is essential in managing Alzheimer disease and other dementias, addressing multiple aspects of the patient’s health and well-being. A comprehensive care plan should out- line treatment goals, medication management strategies, safety measures (e.g., fall prevention), and methods to manage behav- ioral symptoms. It should also include cognitive stimulation activities, social engagement recommendations, and caregiver support and education. Early advance care planning discus- sions are crucial to ensure the patient’s wishes are respected as the disease progresses. Referrals to specialists and community resources should be included for comprehensive support. Person-centered care is vital, involving both the patient and caregivers in the planning process [22]. Healthcare providers should use clear language when explaining assessments and treatment options, encouraging patients to express their prefer- ences and concerns. Caregivers should be included in discussions about care goals and management strategies, as they often play a primary role in day-to-day care. Education about the disease process, expected progression, and available resources should be provided to both patients and caregivers. The needs of the family evolve as Alzheimer disease progresses, and this should be considered at all phases of patient care ( Table 6 ). The importance of advance directives should be discussed, and their completion encour- aged. Regular reviews and updates of the care plan, with input from both the patient and caregiver, ensure its relevance and effectiveness as the disease progresses. Throughout the process,
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MDRI2026
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