The Coding Connection: Cognitive Connection

Has anyone asked you to remember a short list of words, in this case certain nouns?

Well, recently, my husband and I were reading some information about Medicare cognitive screening, and this list of words came up: Apple, Chair, Ocean, Book, and Clock. Over the weekend, we tried to repeat back this list of words to each other twice a day, from memory.

We often hear someone saying “that’s a senior moment,” because they didn’t remember a detail, date, time, or item. Well, it turns out that recalling a list of words a few times during the day can end up being a fun activity.

Some medical experts say that the inability to recall these five words can mark signs of cognitive changes or impairment within the brain – or it could mean that the individual has memory and recall issues.

Sources define “cognitive impairment” as the following:

Cognitive impairment is when an individual has problems remembering things, concentrating, making decisions and solving problems.

Understanding the signs of cognitive impairment are important, and they may include trouble remembering, of course, but also trouble learning new things, concentrating, managing finances, and making decisions. Conditions like depression, anxiety, and delirium can also cause confusion, so it’s important to understand why symptoms arise. Consideration of “age-related” cognitive decline is vital to watch for and assess.

According to online sources, Medicare provides cognitive screening services as part of the Annual Wellness Visit (AWV). This service is designed to detect early signs of cognitive impairment, such as dementia and Alzheimer’s disease. The cognitive assessment includes a detailed history and patient exam, typically conducted by a clinician eligible to report evaluation and management (E&M) services.

The assessment is noninvasive, takes only a few minutes, and can help establish a diagnosis and develop a care plan. Medicare Part B covers this service, and beneficiaries do not have to pay the Part B deductible for the AWV. If cognitive impairment is detected, healthcare professionals and insurers may recommend a more detailed evaluation and care planning.

According to the Centers for Medicare & Medicaid Services (CMS) Medicare website, during a cognitive assessment, the doctor or healthcare provider may undertake the following:

• Perform an exam, talk with you about your medical history, and review your medications;
• Identify your social supports, including care that your usual caregiver can provide;
• Create a care plan to help address and manage your symptoms;
• Help you develop or update your advance care plan;
• Refer you to a specialist, if needed; and
• Help you understand more about community resources, like rehabilitation services, adult day health programs, and support groups.

There’s an interesting article titled “Cognitive Assessment At Medicare’s Annual Wellness Visit In Fee-For-Service And Medicare Advantage Plans”, available at: Cognitive Assessment At Medicare’s Annual Wellness Visit In Fee-For-Service And Medicare Advantage Plans – PMC

In addition, the Alzheimer’s Association has a cognitive assessment toolkit to help with identifying probable cognitive impairment. This was developed by a group of clinical dementia experts; the recommended process allows for the provider to efficiently identify patients with probable cognitive impairment while giving the flexibility to choose a cognitive assessment tool that works best for the provider and their patients. Their toolkit is available at: https://www.alz.org/getmedia/9687d51e-641a-43a1-a96b-b29eb00e72bb/cognitive-assessment-toolkit

In identifying the accurate medical code for a diagnosis of “cognitive impairment,” you will look first in the alphanumeric index under “Impairment,” then see the word “Cognitive,” Mild, of uncertain or unknown etiology. The direction is to go to the tabular to code G31.84, Cognitive Impairment. This will be in Chapter 6, Diseases of the nervous system (G00-G99), of the tabular.

There you’ll find the Category heading of Other Degenerative Diseases of the Nervous System (G30-332). Under this, you’ll see a subcategory list of conditions listed including Alzheimer’s Disease at G30.0-G30.9; continuing down this area, you’ll see G31.84, Mild cognitive impairment of uncertain or unknown etiology. What follows is the complete listings of other descriptions and instructions for this code, including:

• Mild cognitive disorder NOS; and
• Mild neurocognitive disorder of uncertain or unknown etiology.
Use an additional code to identify presence of the following:
• Alcohol abuse and dependence (F10.-);
• Exposure to environmental tobacco smoke (Z77.22);
• History of tobacco dependence (Z87.891) hypertension (I10-I1A);
• Occupational exposure to environmental tobacco smoke (Z57.31);
• Tobacco dependence (F17.-); and
• Tobacco use (Z72.0).

Excludes1:
• Age-related cognitive decline (R41.81);
• Altered mental status (R41.82);
• Cerebral degeneration (G31.9);
• Cerebrovascular diseases (I60-I69);
• Change in mental status (R41.82);

Cognitive deficits following (sequelae of) cerebral hemorrhage or infarction (I69.01-, I69.11-, I69.21-, I69.31-, I69.81-, I69.91-);
Cognitive impairment due to intracranial or head injury (S06.-);
Dementia (F01.-, F02.-, F03.-);
Mild neurocognitive disorder due to a known physiological condition (F06.7-);
Neurologic neglect syndrome (R41.4); and
Personality change, nonpsychotic (F68.8).

It’s extremely important to read and follow these tabular instructions, especially noting the “Use additional code” and “Excludes1” direction.

Finally, always read the clinical documentation in the medical record carefully, completely, and thoroughly. If the documentation is unclear, conflicting, contrasting, or incomplete, then a compliant query should be initiated to the provider for clarification.

Ok, now . . . repeat the list in the title of this article from memory, without looking back at the words.

How did you do?