Cognitive Assessment & Care Plan (CPT 99483)

Build your cognitive care plan

Fill in what you assessed, in any order, and the engine drafts a compliant cognitive care plan for you to review and sign.

You end up with the written care plan, in CMS order, with every required element tracked.

Your answers stay in this browser until you press Generate. Nothing is sent anywhere before that.
Gaps are fine. The checklist below tracks what is still missing, so you can stop and come back.
Free to build, and no account needed. You only pay when you export the PDF.

✓ Your progress is saved on this device as you type.

CPT 994830 of 6 captured

Still to capture before you bill 99483 — tap one to jump to it:

Already have a visit note, scribe output or transcript? We can read it and fill in what it covers.

Patient details

Full name

Date of birth

Age

Sex

Medical record number

Medicare / insurance ID

Primary contact (name, relationship, phone)

Referral source

Encounter details

Provider name

Provider NPI

Provider credentials

Date of encounter

Place of service

Total time spent (minutes) · 99483 has a typical time of ~60 minutes; document actual time.

Independent historian present? · A caregiver/informant is expected for 99483.

Independent historian (name, relationship)

Cognition-focused evaluation (history & exam)

Presenting cognitive concern

Onset / duration

Course

Cognitive domains affected

Pertinent history (medical, psychiatric, family, substance)

Pertinent examination findings

Standardized cognitive test used

Cognitive test score

Dementia staging (standardized instrument)

A standardized staging instrument is REQUIRED for 99483.

Staging instrument

Stage / result

Staging notes

Neuropsychiatric & behavioral symptoms (incl. depression)

A standardized depression screen is REQUIRED for 99483.

Neuropsychiatric / behavioral symptoms

Depression screen used

Depression screen score

Neuropsychiatric notes

Medication reconciliation & high-risk review

Current medications (reconciled)

High-risk medications identified · e.g. anticholinergics, benzodiazepines, sedative-hypnotics, opioids.

Medication recommendations

Medical decision making

MDM complexity · 99483 requires moderate-to-high complexity MDM.

MDM rationale

Care plan

The tool drafts the full written care plan from your assessment when you generate — recommendations for each domain, referrals, and follow-up. You review, edit, and sign. Everything below is optional: add specific directions to steer the draft, and set who the plan is shared with.

Cognitive plan directions · Optional — the draft covers this; add anything specific to include.

Neuropsychiatric plan directions · Optional.

Functional plan directions · Optional.

Referrals

Community resources · e.g. Alzheimer’s Association, adult day programs, respite, caregiver support.

Share the written plan with

Plan will be shared and documented

Supporting documents · optional · PDF or images

Attach medical history, prior reports, or other supporting evidence. They’re read to ground the report — nothing is invented. (Environment photos are captured per area above.)

You’ll confirm you’re authorised and the information is accurate before export. By building a report you agree to the Terms of Use.

This drafts the full written care plan from your assessment — recommendations for each domain, referrals, and a follow-up schedule. You review, edit, and sign.

Nothing to draft from yet. Fill in what you assessed (or attach the patient’s documents) and this builds the care plan from it.