Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements:
- Cognition-focused evaluation including a pertinent history and examination,
- Medical decision making of moderate or high complexity,
- Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity,
- Use of standardized instruments for staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]),
- Medication reconciliation and review for high-risk medications,
- Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s),
- Evaluation of safety (eg, home), including motor vehicle operation, Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks,
- Development, updating or revision, or review of an Advance Care Plan,
- Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support.
Typically, 60 minutes of total time is spent on the date of the encounter.
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