Cognitive Assessment and Care Plan Service

Medicare covers a separate Cognitive Assessment and Care Plan service when cognitive impairment is identified during an AWV, routine visit, or via collateral information; any clinician eligible to bill E/M services (MD/DO, NP, CNS, CNM, PA) may perform it in person or via telehealth. Coverage requires comprehensive, documented cognition-focused evaluation with moderate/high complexity MDM, standardized validated assessment tools (with raw scores available), functional and safety assessments, medication reconciliation, caregiver assessment, advance care planning, and a written care plan shared with the patient/caregiver; missing documentation of any required element may result in denial. A formal care-plan update is recommended at least annually, and ancillary staff may perform components only if fully documented incident to the billing practitioner.

"Medicare covers a separate cognitive assessment and care plan visit when cognitive impairment is detected as part of the Annual Wellness Visit (AWV)."