CPT 99483 · Free tool
CPT 99483 Documentation Checklist
Every element an auditor looks for on a 99483 cognitive assessment and care plan — the six that are required (miss one and the claim fails) plus the full recommended set. Print it, or get it emailed to keep on file for your team.
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CPT 99483 — Cognitive Assessment & Care Plan · Documentation Checklist
Required — the claim fails without every one of these
- Standardized dementia staging instrument + resultElement 4 — record a staging instrument (FAST or CDR) AND its stage/result. Required; the claim fails without it.
- Standardized depression screen + scoreElement 6 — record a depression screen (PHQ-9 or GDS) AND its score. Required.
- Independent historianA caregiver/informant is expected for 99483.
- Total time documentedDocument the total time spent (typical ~60 minutes).
- Medical decision making — moderate or highElement 2 — 99483 requires moderate-to-high complexity MDM.
- Written care plan shared with patient / caregiverElement 10 — the written plan must be created and shared.
Also document — the full 99483 element set
- Cognition-focused evaluation (test + score)Element 1 — record the cognitive test (MoCA/MMSE/Mini-Cog) and score.
- Functional assessment (ADL / IADL / capacity)Element 3.
- Medication reconciliationElement 5.
- Safety evaluation (home + driving)Element 7.
- Caregiver identifiedElement 8.
Or capture all of it in one pass
ClinicalAssessment.io walks every required element in a single structured flow and assembles the compliant care plan for you to review and sign — built by a physician. No checklist to remember.
Clinically reviewed by Dr Adeyinka Adegbosin (MBBS, PhD). General information, not billing or legal advice — verify current CMS requirements, frequency, and payment for your year and locality.