Dementia: Cognitive Assessment (2022)
eCQMs / NQF #: | CMS149v10 / 2872e |
Measure: | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period. |
Numerator: | Patients for whom an assessment of cognition is performed, and the results reviewed at least once within a 12-month period. |
Denominator: | All patients, regardless of age, with a diagnosis of dementia. |
Denominator Exceptions: | Documentation of patient reason(s) for not assessing cognition. |
Domain: | Effective Clinical Care |
In ChartMaker Clinical:
In order to qualify for this measure, the provider must have seen the patient at least twice during the reporting period and have the appropriate information documented in the chart:
Required Data Elements for the Denominator:
ICD-10: | |
Code | Description |
A52.17 | General paresis |
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 |
F05 | Delirium due to known physiological condition |
F06.8 | Other specified mental disorders due to known physiological condition |
G30.0 | Alzheimer’s disease with early onset |
G30.1 | Alzheimer’s disease with late onset |
G30.8 | Other Alzheimer’s disease |
G30.9 | Alzheimer’s disease, unspecified |
G31.01 | Pick’s disease |
G31.09 | Other frontotemporal dementia |
G31.83 | Dementia with Lewy bodies |
SNOMED: | |
Code | Description |
10349009 | Multi-infarct dementia with delirium (disorder) |
10532003 | Primary degenerative dementia of the Alzheimer type, presenile onset, with depression (disorder) |
111480006 | Psychoactive substance-induced organic dementia (disorder) |
12348006 | Presenile dementia (disorder) |
14070001 | Multi-infarct dementia with depression (disorder) |
15662003 | Senile dementia (disorder) |
191449005 | Uncomplicated senile dementia (disorder) |
191451009 | Uncomplicated presenile dementia (disorder) |
191452002 | Presenile dementia with delirium (disorder) |
191454001 | Presenile dementia with paranoia (disorder) |
191455000 | Presenile dementia with depression (disorder) |
191457008 | Senile dementia with depressive or paranoid features (disorder) |
191458003 | Senile dementia with paranoia (disorder) |
191459006 | Senile dementia with depression (disorder) |
191461002 | Senile dementia with delirium (disorder) |
191463004 | Uncomplicated arteriosclerotic dementia (disorder) |
191464005 | Arteriosclerotic dementia with delirium (disorder) |
191465006 | Arteriosclerotic dementia with paranoia (disorder) |
191466007 | Arteriosclerotic dementia with depression (disorder) |
191493005 | Drug-induced dementia (disorder) |
22381000119105 | Primary degenerative dementia (disorder) |
230258005 | Amyotrophic lateral sclerosis with dementia (disorder) |
230270009 | Frontotemporal dementia (disorder) |
230282000 | Post-traumatic dementia (disorder) |
230283005 | Punch drunk syndrome (disorder) |
230285003 | Vascular dementia of acute onset (disorder) |
230286002 | Subcortical vascular dementia (disorder) |
230287006 | Mixed cortical and subcortical vascular dementia (disorder) |
230288001 | Semantic dementia (disorder) |
230289009 | Patchy dementia (disorder) |
25772007 | Multi-infarct dementia with delusions (disorder) |
26852004 | Primary degenerative dementia of the Alzheimer type, senile onset, with depression (disorder) |
278857002 | Dementia of frontal lobe type (disorder) |
279982005 | Cerebral degeneration presenting primarily with dementia (disorder) |
281004 | Dementia associated with alcoholism (disorder) |
31081000119101 | Presenile dementia with delusions (disorder) |
312991009 | Senile dementia of the Lewy body type (disorder) |
32875003 | Inhalant-induced persisting dementia (disorder) |
371024007 | Senile dementia with delusion (disorder) |
371026009 | Senile dementia with psychosis (disorder) |
416780008 | Primary degenerative dementia of the Alzheimer type, presenile onset (disorder) |
420614009 | Organic dementia associated with acquired immunodeficiency syndrome (disorder) |
421023003 | Presenile dementia associated with acquired immunodeficiency syndrome (disorder) |
421529006 | Dementia associated with acquired immunodeficiency syndrome (disorder) |
425390006 | Dementia associated with Parkinson’s Disease (disorder) |
429458009 | Dementia due to Creutzfeldt Jakob disease (disorder) |
429998004 | Vascular dementia (disorder) |
430771000124100 | Moderate dementia (disorder) |
442344002 | Dementia due to Huntington chorea (disorder) |
4817008 | Primary degenerative dementia of the Alzheimer type, senile onset, with delirium (disorder) |
51928006 | General paresis – neurosyphilis (disorder) |
52448006 | Dementia (disorder) |
54502004 | Primary degenerative dementia of the Alzheimer type, presenile onset, with delusions (disorder) |
55009008 | Primary degenerative dementia of the Alzheimer type, senile onset, with delusions (disorder) |
56267009 | Multi-infarct dementia (disorder) |
59651006 | Sedative, hypnotic AND/OR anxiolytic-induced persisting dementia (disorder) |
6475002 | Primary degenerative dementia of the Alzheimer type, presenile onset, uncomplicated (disorder) |
65096006 | Primary degenerative dementia of the Alzheimer type, presenile onset, with delirium (disorder) |
66108005 | Primary degenerative dementia of the Alzheimer type, senile onset, uncomplicated (disorder) |
698624003 | Dementia associated with cerebral lipidosis (disorder) |
698625002 | Dementia associated with normal pressure hydrocephalus (disorder) |
698626001 | Dementia associated with multiple sclerosis (disorder) |
698687007 | Post-traumatic dementia with behavioral change (disorder) |
698725008 | Dementia associated with neurosyphilis (disorder) |
698726009 | Dementia associated with viral encephalitis (disorder) |
698781002 | Dementia associated with cerebral anoxia (disorder) |
702393003 | Frontotemporal dementia with gene located on 3p11 (disorder) |
702426001 | GRN-related frontotemporal dementia (disorder) |
702429008 | Frontotemporal dementia with parkinsonism-17 (disorder) |
703544004 | Inclusion body myopathy with early-onset Paget disease and frontotemporal dementia (disorder) |
70936005 | Multi-infarct dementia, uncomplicated (disorder) |
713488003 | Presenile dementia co-occurrent with human immunodeficiency virus infection (disorder) |
713844000 | Dementia co-occurrent with human immunodeficiency virus infection (disorder) |
715737004 | Parkinsonism co-occurrent with dementia of Guadeloupe (disorder) |
716667005 | Right temporal atrophy variant frontotemporal dementia (disorder) |
716994006 | Behavioral variant of frontotemporal dementia (disorder) |
722977005 | Dementia co-occurrent and due to neurocysticercosis (disorder) |
722978000 | Dementia caused by toxin (disorder) |
722979008 | Dementia due to metabolic abnormality (disorder) |
722980006 | Dementia due to chromosomal anomaly (disorder) |
723123001 | Ischemic vascular dementia (disorder) |
723390000 | Rapidly progressive dementia (disorder) |
724776007 | Dementia due to disorder of central nervous system (disorder) |
724777003 | Dementia due to infectious disease (disorder) |
724992007 | Epilepsy co-occurrent and due to dementia (disorder) |
725898002 | Delirium co-occurrent with dementia (disorder) |
733184002 | Dementia caused by heavy metal exposure (disorder) |
733185001 | Dementia following injury caused by exposure to ionizing radiation (disorder) |
733190003 | Dementia due to primary malignant neoplasm of brain (disorder) |
733191004 | Dementia due to chronic subdural hematoma (disorder) |
733192006 | Dementia due to herpes encephalitis (disorder) |
733193001 | Dementia co-occurrent and due to progressive multifocal leukoencephalopathy (disorder) |
733194007 | Dementia co-occurrent and due to Down syndrome (disorder) |
762350007 | Dementia due to prion disease (disorder) |
762351006 | Dementia due to and following injury of head (disorder) |
762707000 | Subcortical dementia (disorder) |
79341000119107 | Mixed dementia (disorder) |
82959004 | Dementia paralytica juvenilis (disorder) |
838276009 | Amyotrophic lateral sclerosis, parkinsonism, dementia complex (disorder) |
90099008 | Subcortical leukoencephalopathy (disorder) |
9345005 | Dialysis dementia (disorder) |
This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.
CPT: | |
Code | Description |
90791 | Psychiatric diagnostic evaluation |
90792 | Psychiatric diagnostic evaluation with medical services |
90832 | Psychotherapy, 30 minutes with patient |
90834 | Psychotherapy, 45 minutes with patient |
90837 | Psychotherapy, 60 minutes with patient |
96116 | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour |
97165 | Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
97166 | Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
97167 | Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
97168 | Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
99201 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. |
99202 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. |
99203 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. |
99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. |
99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. |
99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. |
99241 | Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family. |
99242 | Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
99243 | Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. |
99244 | Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. |
99125 | Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family. |
99304 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99305 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99306 | Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99307 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99308 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99309 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99310 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99315 | Nursing facility discharge day management; 30 minutes or less |
99316 | Nursing facility discharge day management; more than 30 minutes |
99318 | Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. |
99324 | Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. |
99325 | Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. |
99326 | Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. |
99327 | Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. |
99328 | Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. |
99334 | Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. |
99335 | Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. |
99336 | Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. |
99337 | Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. |
99341 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. |
99342 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. |
99343 | Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. |
SNOMED: | |
Code | Description |
10197000 | Psychiatric interview and evaluation (procedure) |
165172002 | Diagnostic psychiatric interview (procedure) |
17436751 | Medical consultation with outpatient (procedure) |
18170008 | Subsequent nursing facility visit (procedure) |
183381005 | General psychotherapy (regime/therapy) |
183382003 | Psychotherapy – behavioral (regime/therapy) |
183383008 | Psychotherapy – cognitive (regime/therapy) |
18512000 | Individual psychotherapy (regime/therapy) |
185316757 | Indirect encounter (procedure) |
185317003 | Telephone encounter (procedure) |
185318008 | Third party encounter (procedure) |
185320006 | Encounter by computer link (procedure) |
185321005 | Letter encounter to patient (procedure) |
185467508 | Home visit request by patient (procedure) |
185462000 | Home visit request by relative (procedure) |
185466752 | Home visit for urgent condition (procedure) |
185467006 | Home visit for acute condition (procedure) |
185468001 | Home visit for chronic condition (procedure) |
185470005 | Home visit elderly assessment (procedure) |
185349003 | Encounter for check up (procedure) |
185463005 | Visit out of hours (procedure) |
185464004 | Out of hours visit – not night visit (procedure) |
185465003 | Weekend visit (procedure) |
207195004 | History and physical examination with evaluation and management of nursing facility patient (procedure) |
209099002 | History and physical examination with management of domiciliary or rest home patient (procedure) |
210098006 | Domiciliary or rest home patient evaluation and management (procedure) |
225929007 | Joint home visit (procedure) |
270424005 | Letter encounter from patient (procedure) |
270427003 | Patient-initiated encounter (procedure) |
270430005 | Provider-initiated encounter (procedure) |
281036757 | Follow-up consultation (procedure) |
302242004 | Long-term psychodynamic psychotherapy (regime/therapy) |
30346759 | Evaluation and management of established outpatient in office or other outpatient facility (procedure) |
304820009 | Developmental psychodynamic psychotherapy (regime/therapy) |
304822001 | Psychodynamic-interpersonal psychotherapy (regime/therapy) |
307808008 | Neuropsychological testing (procedure) |
308335008 | Patient encounter procedure (procedure) |
308720009 | Letter encounter (procedure) |
314034001 | Psychodynamic psychotherapy (regime/therapy) |
315205008 | Bank holiday home visit (procedure) |
3391000175108 | Office visit for pediatric care and assessment (procedure) |
37894004 | Evaluation and management of new outpatient in office or other outpatient facility (procedure) |
386473003 | Telephone follow-up (procedure) |
38678006 | Client-centered psychotherapy (regime/therapy) |
390906757 | Follow-up encounter (procedure) |
401157001 | Brief solution focused psychotherapy (regime/therapy) |
401267002 | Telephone triage encounter (procedure) |
401271004 | E-mail sent to patient (procedure) |
406547006 | Urgent follow-up (procedure) |
410155007 | Occupational therapy assessment (procedure) |
410157004 | Occupational therapy management (procedure) |
438515009 | E-mail encounter from carer (procedure) |
438516755 | E-mail encounter to carer (procedure) |
439708006 | Home visit (procedure) |
439740005 | Postoperative follow-up visit (procedure) |
443730003 | Interpersonal psychotherapy (regime/therapy) |
445450000 | Encounter by short message service text messaging (procedure) |
448337001 | Telemedicine consultation with patient (procedure) |
68338001 | Interactive medical psychiatric diagnostic interview (procedure) |
698704008 | Home visit for rheumatology service (procedure) |
704126758 | Home visit for anticoagulant drug monitoring (procedure) |
75516751 | Psychotherapy (regime/therapy) |
77406758 | Confirmatory medical consultation (procedure) |
79094001 | Initial psychiatric interview with mental status and evaluation (procedure) |
87790002 | Follow-up inpatient consultation visit (procedure) |
90102008 | Social psychotherapy (regime/therapy) |
90526750 | Initial evaluation and management of healthy individual (procedure) |
Denominator Exceptions:
This can be captured in the Screening dialog, by selecting a reason in the Screening not done for patient reason drop-down list of the Blessed Orientation Memory Concentration Test (Cognitive Assessment) screening.
Required Data Elements for the Numerator:
This can be captured by completing the Blessed Orientation Memory Concentration Test (Cognitive Assessment) via the Screening widget.
The questionnaire is accessed by clicking the corresponding button at the top of the dialog. After the questionnaire is accessed, you can configure the answers for the various questions. Do note if the answer to the first question (Screening not done for patient reason), is anything other than No or blank (unanswered), the assessment questionnaire sections below will be grayed out and no score will be given.
The Repeat the memory phrase… link provides access to detailed information on how to score this aspect of the questionnaire.
The various assessment questions have a measured Total Score based on the answered questions allowing you to quickly determine if the patient assessment is consistent with dementia and thereby offer further testing or treatment as needed. If you click the Total Score link, additional information is provided about how the scoring is conducted.
The Note Output options at the bottom of the dialog provides you with choices to determine how this information is outputted to the note. You can choose to output only the Title, to output the configured information in List format, or to output the configured information in Paragraph format, or to output the Title & Score.
ADDITIONAL INFORMATION:
- Cognition can be assessed by the clinician during the patient’s clinical history.
- The only data used to determine the denominator is data from ChartMaker Clinical. If a patient encounter was not entered into Clinical, that encounter is not included in the denominator for the statistical calculations on the MIPS Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.