Does 99242 require prior authorization?

No, 99242 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 99242?

Medicare facility rate: $55.45. Non-facility rate: $75.15. Work RVU: 1.08.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.08

Facility

$55.45

Non-Facility

$75.15

Document cognitive-relevant history including factors potentially contributing to impairment (for example psychoactive medications, chronic pain, infection, depression, other brain diseases).
Document medical decision making that supports moderate-to-high complexity, including current and likely disease progression and the need for referrals for rehabilitative, social, legal, financial, or community services.
Document use of standardized, validated cognitive assessment tools and retain full instrument raw scoring and results in the medical record for Medicare Administrative Contractor review if requested.
Document assessment of cognition using one of the accepted tools (Mini-Cog, GPCOG, or short MoCA) with results present in the medical record.

CPT 99483 is covered for Medicare beneficiaries who are cognitively impaired, including those diagnosed with Alzheimer’s disease, other dementias, or mild cognitive impairment.
CPT 99483 is covered when the clinician, based on observation or corroborating information from patient/family/caregiver/others, determines the patient is cognitively impaired even if no formal diagnosis yet exists, provided documentation confirms impairment and the narrative history that prompted suspicion.
Coverage applies when a comprehensive visit results in a written care plan and includes all required elements of the 99483 service (cognition-focused evaluation, moderate-to-high MDM, functional assessment, dementia staging, medication reconciliation, neuropsychiatric evaluation, safety evaluation, caregiver identification/needs, advance care planning, and written care plan shared at initial education/support).
Medicare covers a separate cognitive assessment and care plan visit when cognitive impairment is detected as part of the Annual Wellness Visit (AWV).
Coverage is allowed when cognitive impairment is suspected during a routine visit based on direct clinical observation or a brief cognitive test.
Coverage is allowed when concern for cognitive impairment arises from information provided by the patient, family, friends, caregivers, or others.

A59036 — Billing and Coding: Cognitive Assessment and Care Plan Service

L39266 — Cognitive Assessment and Care Plan Service

ANTHEM-CG-MED-61 — CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries

Ask Verity about documentation requirements, denial risks, or coverage in your state.