Guidance for annual cognitive health assessment for eligible members 65 years of age or older

Purpose

The purpose of this bulletin is to provide guidance on the provision of an annual Medi-Cal cognitive health assessment for members 65 years of age or older.

Background

California Senate Bill (SB) 48 (Chapter 484, Statutes of 2021) expands the Medi-Cal schedule of benefits to include an annual cognitive assessment for Medi-Cal members who are 65 years of age and older if they are otherwise ineligible for a similar assessment as part of an annual wellness visit through the Medicare program, subject to an appropriation by the state legislature for this purpose as of July 1, 2022. The annual cognitive health assessment is intended to identify whether the patient has signs of Alzheimer’s disease or related dementias, consistent with the standards for detecting cognitive impairment under the Medicare annual wellness visit and the recommendations by the American Academy of Neurology.

Additionally, SB 48 outlines requirements that Medi-Cal providers must complete prior to being eligible to receive payment for conducting annual cognitive health assessments. Medi-Cal providers must complete training as specified and approved by the Department of Health Care Services (DHCS) and use validated tools recommended by the DHCS.

Policy

The annual cognitive health assessment is for members 65 years of age or older who do not have Medicare coverage. Trained providers who render the assessment will bill with CPT^® code 1494F. The code is allowable once per year as part of the member’s annual exam.

Provider billing requirements

To appropriately bill and receive reimbursement for conducting an annual cognitive health assessment, providers must do all of the following:

• Complete the DHCS Dementia Care Aware cognitive health assessment training (dementiacareaware.org) prior to conducting the brief cognitive health assessment:
  • Anthem Blue Cross (Anthem) will have access to a list of providers who have completed the training.
• Administer the annual cognitive health assessment as a component of an evaluation and management visit including but not limited to an office visit, consultation, or preventative medicine service (elements of the cognitive health assessment can be conducted by non-billing team members acting within their scope of practice and under the supervision of the billing provider).
• Document all the following in the member’s medical records and have such records available upon request:
  • The screening tool or tools that were used (at least one tool from the cognitive assessment tools section below is required)
  • Verification that screening results were viewed by the provider
  • The results of the screening
  • The interpretation of results
  • Details discussed with the member and/or authorized representative and any appropriate actions taken regarding screening results
• Use CPT code 1494F as outlined in the Medi-Cal Provider Manual. For further assistance, contact your Provider Relationship Management associate.

Cognitive assessment tools

At least one cognitive assessment tool listed below is also required. Cognitive assessment tools used to determine if a full dementia evaluation is needed include, but are not limited to:

• Patient assessment tools:
  • General Practitioner Assessment of Cognition (GPCOG)
  • Mini-Cog
• Informant tools (family members and close friends):
  • Eight-Item Informant Interview to Differentiate Aging and Dementia
  • GPCOG
  • Informant Questionnaire on Cognitive Decline in the Elderly

Medical record reviews

To ensure the provision of appropriate and necessary follow-up services based on assessment scores, including but not limited to additional assessment or specialist referrals, the plan may conduct random medical record reviews.

Members under 65 years of age

Anthem will cover medically necessary and appropriate coverage of assessments for members under 65 years of age who are reporting symptoms or showing signs of cognitive decline. This may include but is not limited to cognitive health assessments, appropriate treatment services, and necessary referrals billed through established practices.

Resources

Providers can view the required training at dementiacareaware.org.