Memory Complaints in the Florida Exam Room: A Physician Guide

A seventy-one-year-old retired schoolteacher comes in for her Medicare wellness visit with her daughter. The patient says her memory is fine for her age. The daughter waits until her mother steps out and then says that her mother missed two bill payments this spring and got lost driving home from a church she has attended for twenty years. Twenty of the visit’s thirty minutes are gone.

I have spent my career as a fellowship-trained neurologist seeing what happens on the other side of that visit, and the outcome usually depends on what the first physician did with the ten remaining minutes. “Memory concern, follow up in a year” hands the family a year of worry and a narrower set of options. A three-minute structured test and a booked cognitive assessment visit put the patient on a path that can now end in a treatment decision.

Why the Office Visit Is Where This Starts

The Alzheimer’s Association counts 580,000 Floridians aged 65 and older living with Alzheimer’s dementia, cared for by an estimated 877,000 unpaid family caregivers, and reports that 15.8 percent of Florida adults aged 45 and older describe subjective cognitive decline. Florida’s Department of Elder Affairs funds 17 Memory Disorder Clinics for the whole state, and the 2026 Alzheimer’s Disease Facts and Figures report found that 55 percent of primary care physicians nationally say there are not enough dementia specialists in their communities. Most Floridians with a new memory complaint will therefore be evaluated first, and often only, by the physician they already see.

What Medicare Already Asks of You

The Annual Wellness Visit regulation at 42 CFR 410.15 requires detection of any cognitive impairment by direct observation, with due consideration of patient report and concerns raised by family members, friends, caretakers or others. It does not name a tool. The Alzheimer’s Association’s wellness visit algorithm, published by Cordell and colleagues in 2013, fills the gap with brief instruments: the Mini-Cog or GPCOG for the patient, each taking about three minutes, and the AD8 or short IQCODE for the informant. A Mini-Cog of 3 or less or an AD8 of 2 or more triggers a full evaluation rather than a note to recheck next year.

That full evaluation has its own code. CPT 99483, cognitive assessment and care plan services, pays for roughly sixty minutes that include a cognition-focused examination, functional assessment, staging, medication reconciliation, neuropsychiatric screening, a safety evaluation covering the home and driving, caregiver assessment, advance care planning, and a written care plan. An independent historian has to be present, which means the daughter stays in the room. It cannot be billed on the same day as an ordinary office visit, so the schoolteacher’s wellness visit should end with that appointment on the calendar.

The Workup Before Any Biomarker

The cognitive assessment visit is where the physician earns the diagnosis, and it comes before any test that measures amyloid. The history should establish the time course and whether function has changed, because mild cognitive impairment and dementia are distinguished by function rather than by a score. The medication list deserves a slow read for anticholinergics and benzodiazepines. Depression, sleep apnea, hearing loss, hypothyroidism, B12 deficiency, and alcohol use have to be excluded, and MRI looks for vascular disease, normal pressure hydrocephalus, or a mass. At the end of that visit the chart should hold one of three sentences: subjective complaints with normal testing and intact function; mild cognitive impairment with objective deficits and preserved independence; or dementia, with a stage. Only the second and third lead to the question the blood tests were built to answer.

What the Blood Tests Can and Cannot Do

On May 16, 2025, the FDA cleared the Lumipulse G pTau217/β-Amyloid 1-42 Plasma Ratio from Fujirebio, the first blood test for use in diagnosing Alzheimer’s disease. The label is narrow: adults aged 55 and older who already show signs and symptoms of cognitive decline and who are being evaluated in a specialized care setting. In the clearance study of 499 cognitively impaired adults, 91.7 percent of positive results and 97.3 percent of negative results agreed with amyloid PET or cerebrospinal fluid testing, and fewer than 20 percent were indeterminate. The FDA stated in the same announcement that the test is not a screening test and not a stand-alone diagnostic test.

In July 2025 the Alzheimer’s Association published its first clinical practice guideline on blood-based biomarkers, led by Sebastian Palmqvist in Alzheimer’s and Dementia. It applies to patients with cognitive impairment evaluated in specialized care and sets two tiers: a test with at least 90 percent sensitivity and 75 percent specificity can serve as a triage test whose positive results still need PET or CSF confirmation, and a test with at least 90 percent sensitivity and 90 percent specificity can substitute for PET or CSF altogether. The panel added that a blood biomarker should not be ordered before a full clinical evaluation, and that not all commercial tests have been validated to the same standard.

For the Florida office this means the blood test is a confirmation tool for a patient already found to have objective cognitive impairment, not a way to settle a worried patient’s question about her future. Ordering plasma p-tau217 on a cognitively normal sixty-year-old because her mother had Alzheimer’s produces a number that no guideline tells you how to act on.

Why the Answer Changes What Happens Next

The reason to confirm amyloid is that treatment now depends on it. Lecanemab, sold as Leqembi, and donanemab, sold as Kisunla, are both labeled for the mild cognitive impairment or mild dementia stage of Alzheimer’s disease, and both labels require confirmation of amyloid beta pathology before the first infusion. The Leqembi label recommends ApoE ε4 genotyping before treatment because homozygotes have a higher incidence of amyloid-related imaging abnormalities, which carry a boxed warning. The stage restriction is what puts the clock on the primary care office. A patient who has progressed to moderate dementia by the time she reaches a memory clinic is outside the labeled population, so early detection is now a matter of treatment eligibility, and it happens at the wellness visit or not at all.

What Florida Physicians Can Do Now

1. Pick one patient tool and one informant tool for the wellness visit, load them into your EHR, and use them on every patient 65 and older. The Mini-Cog and the AD8 together take under six minutes.
2. Build the 99483 visit as a standing appointment type with its own template, scheduled with the family member who raised the concern.
3. Keep a referral sheet with the Memory Disorder Clinic that serves your area and the Elder Helpline at 1-800-963-5337, which routes families to their Area Agency on Aging for respite and case management under the Alzheimer’s Disease Initiative.
4. Decide in advance when your practice will order a plasma p-tau217 test: objective impairment on testing, a completed reversible-cause workup, age 55 or older, and a patient who would be a candidate for anti-amyloid therapy if positive. Do not order it for asymptomatic patients.
5. Ask the neurologist or geriatrician you refer to what they want in the chart before the visit, so the months of waiting are spent completing the workup rather than starting it.

The Bigger Picture

Florida has more people living with Alzheimer’s disease than any state except California, and our March piece on the fragmented patient described what waiting for a specialist does to a family. The physicians who see these patients first now have the authority, the billing code, and the diagnostic tools to do most of the work that used to be sent away.

Frequently Asked Questions

Is cognitive screening required at the Medicare Annual Wellness Visit?

Detection of any cognitive impairment is a required element of the Annual Wellness Visit under 42 CFR 410.15. The regulation requires assessment by direct observation with consideration of patient and family concerns, and it does not mandate a specific instrument, though the Alzheimer’s Association recommends a brief structured tool such as the Mini-Cog or GPCOG.

Can a Florida primary care physician order the Alzheimer’s blood test?

The FDA-cleared Lumipulse plasma test is labeled for adults 55 and older with signs and symptoms of cognitive decline in a specialized care setting, and the Alzheimer’s Association guideline is written for specialists. A primary care physician who has documented objective impairment and completed the reversible-cause workup can order it, ideally in coordination with the neurologist who will see the patient, but it should not be used to screen asymptomatic patients.

How accurate is the plasma p-tau217 blood test for Alzheimer’s disease?

In the FDA clearance study of 499 cognitively impaired adults, 91.7 percent of positive results and 97.3 percent of negative results agreed with amyloid PET or cerebrospinal fluid testing, and fewer than 20 percent of results were indeterminate. The Alzheimer’s Association guideline treats a test with at least 90 percent sensitivity and 90 percent specificity as a substitute for PET or CSF in specialty care.

What does CPT 99483 cover and who can bill it?

CPT 99483 covers a cognitive assessment and care plan visit of roughly sixty minutes that includes a cognition-focused exam, functional assessment, staging, medication reconciliation, neuropsychiatric screening, a safety evaluation, caregiver assessment, advance care planning, and a written care plan. Physicians, nurse practitioners, clinical nurse specialists, and physician assistants can bill it, in the office, at home, in a facility, or by telehealth.

Where can Florida physicians refer patients for a memory evaluation and caregiver support?

The Florida Department of Elder Affairs funds 17 Memory Disorder Clinics in 13 service areas that provide testing, education, and referral, and the Alzheimer’s Disease Initiative provides respite and case management through the 11 Area Agencies on Aging. Families can reach their local agency through the Elder Helpline at 1-800-963-5337.

This article is general clinical information for physicians and does not replace individual clinical judgment, product labeling, or payer coverage rules.

This article was drafted with the assistance of AI writing tools, then reviewed, edited, and approved by Dr. Sean C. Orr, M.D., who holds full editorial responsibility for its content. The header illustration was created with AI image tools.

References

1. Alzheimer’s Association. Florida state overview: Alzheimer’s statistics. alz.org
2. Alzheimer’s Association. 2026 Alzheimer’s Disease Facts and Figures. Alzheimer’s and Dementia, 2026. alz.org
3. Florida Department of Elder Affairs. Alzheimer’s Disease Initiative and Memory Disorder Clinics (summary via FSU College of Medicine REACH). reach.med.fsu.edu
4. 42 CFR § 410.15, Annual wellness visits providing personalized prevention plan services. law.cornell.edu
5. Alzheimer’s Association. Cognitive assessment algorithm for the Medicare Annual Wellness Visit (Cordell et al., 2013). alz.org
6. Centers for Medicare and Medicaid Services. Cognitive Assessment and Care Plan Services (CPT 99483). cms.gov
7. U.S. Food and Drug Administration. FDA Clears First Blood Test Used in Diagnosing Alzheimer’s Disease. May 16, 2025. fda.gov
8. Palmqvist S, Whitson HE, Allen LA, et al. Alzheimer’s Association Clinical Practice Guideline on the use of blood-based biomarkers in the diagnostic workup of suspected Alzheimer’s disease within specialized care settings. Alzheimer’s and Dementia. 2025;21(7):e70535. doi.org
9. Patient Care Online. Alzheimer’s Association Releases First Clinical Guideline on Use of Blood-Based Biomarker Tests. July 30, 2025. patientcareonline.com
10. Leqembi (lecanemab-irmb) prescribing information, 2025. accessdata.fda.gov
11. WUSF Health News Florida. South Florida’s relationship with Alzheimer’s runs deep; access to care remains a challenge. July 22, 2026. wusf.org