Care for Older Adult (COA) Assessment
DATE
PATIENT NAME (Last, First)
WEIGHT:
HEIGHT:
FT.
IN.
LBS.
DOES PATIENT HAVE ADVANCE DIRECTIVE?
YES NO
CPT Codes: 1157F, 1158F HCPCS: S0257
MEDICATION RECONCILIATION- Cat II Code: 1159F HCPCS: G8427 (MEDICATION LIST MUST BE INCLUDED)
WAS THE MEDICATION LIST ATTACHED, REVIEWED BY A PHYSICIAN YES NO
99605, 99606, 90863 Cat II Code: 1160F
BMI Reading required – (ICD-9-CM Diagnosis Codes V85.0 ─ V85.45) **
V85.0 BMI below 19
V85.1 BMI between 19-24
V85.21 BMI 25.0-25.9
V85.22 BMI 26.0-26.9
V85.23 BMI 27.0-27.9
V85.24 BMI 28.0-28.9
V85.25 BMI 29.0-29.9
V85.30 BMI 30.0-30.9
V85.31 BMI 31.0-31.9
V85.32 BMI 32.0-32.9
V85.33 BMI 33.0-33.9
V85.34 BMI 34.0-34.9
V85.35 BMI 35.0-35.9
V85.36 BMI 36.0-36.9
V85.37 BMI 37.0-37.9
V85.38 BMI 38.0-38.9
V85.39 BMI 39.0-39.9
V85.41 BMI 40.0-44.9
V85.42 BMI 45.0-49.99
V85.43 BMI 50-59.9
V85.44 BMI 60.0-69.9
V85.45 BMI 70 and
over
Current Level of Function (Compare to initial assessment.) Category II Codes: 1170F
ADL
MOBILITY
BALANCE
MENTAL STATUS
COMMUNICATIONS
INDEPENDENT
 MINIMAL ASSISTANCE
 NEEDS ASSISTANCE
TOTAL ASSIST
CONTROLS/MOVES ALL LIMBS AT WILL AND SAFELY INDEPENDENT  CONTROLS/MOVES ALL LIMBS WITH MIN ASSTANCE
 REQUIRES 2 PERSONS FOR XFER UNABLE TO POSITION CHANGE/MECHANICAL LIFT XFER
NORMAL  MIN ASSISTANCE WITH BALANCE  UNSAFE BALANCE AND NEEDS MOD ASSISTANCE
MAXASSISTANCENEEDEDWITH1-2PERSONS
ORIENTED x3
ORIENTED x2 FOLLOWS SIMPLE COMMANDS
ORIENTED X1, INCONSISTENTLY RESTLESS, AGITATED OR NERVOUS UNRESPONSIVE TO VERBAL COMMANDS
IMPROVED
 DECLINED
 UNCHANGED
Pain Assessment - Category II Codes: 1125F, 1126F
Location:
Intensity. On a scale of 0 to 10, with 0 being no pain and
10 being the worst pain you can imagine, how much does
it hurt right now??
Is this pain constant?
YES NO
TYPE OF PAIN (Example: ache, deep, sharp, hot, cold, like sensitive skin, sharp)
ONSET, DURATION, VARIATIONS
WHAT RELIEVES PAIN?
WHAT CAUSES OR INCREASES PAIN?
TREATMENT PLAN
OTHER COMMENTS

PHYSICIAN SIGNATURE
DATE
(SI 9/19/13)
Page 2
Care of Older Adults Assessment Codes and Descriptions
Codes
Descriptions
Descriptions - 2014 CPT Book
Category II
1170F
Functional Status Assessment: At least one functional status
assessment during the measurement year. Notations for a complete
functional status assessment include: notation that Instrumental
Activities of Daily Living (IADL) were assessed; Result of assessment
using a standardized functional status assessment tool; notation of at
least three of the following four components were assessed: cognitive
status, ambulation status, sensory ability, or other function
independence.
Functional status assessed (COA)
1125F
Pain Screening: At least one comprehensive pain screening or pain
management plan during the measurement year.
Pain severity quantified; pain present
(COA)
1126F
Pain Screening: At least one comprehensive pain screening or pain
management plan during the measurement year.
No pain present (COA)
Advance Care Planning: Evidence of advance care planning during the
measurement year. Advanced care planning is a discussion about
preferences for resuscitation, life-sustaining treatment and end of life
care.
Advance care plan or similar legal
document present in the medical
record (COA)
1158F
Advance Care Planning: Evidence of advance care planning during the
measurement year. Advanced care planning is a discussion about
preferences for resuscitation, life-sustaining treatment and end of life
care.
Advance care planning discussion
documented in the medical record
(COA)
1159F
Medication Review: A medication review conducted and the presence
of a medication list in the medical record during measurement year.
Medication list documented in medical
record(COA)
1160F
Medication Review: A medication review conducted and the presence
of a medication list in the medical record during measurement year.
Review of all medications by a
prescribing practitioner or clinical
pharmacist (such as, prescriptions,
OTCs, herbal therapies and
supplements) documented in the
medical record (COA)
90863
Medication Review: A medication review conducted and the presence
of a medication list in the medical record during measurement year.
Pharmacologic management, including
prescription, use, and review of
medication with no more than minimal
medical psychotherapy
99605
Medication Review: A medication review conducted and the presence
of a medication list in the medical record during measurement year.
Medication therapy management
service(s) pro- vided by a pharmacist,
individual, face-to-face with patient,
with assessment and intervention if
provided; initial 15 minutes, new
patient
99606
Medication Review: A medication review conducted and the presence of Initial 15 minutes, established patient
a medication list in the medical record during measurement year.
1157F