CPT 99483 · Cognitive Assessment & Care Plan

The 99483 required elements, as a form you can finish.

Medicare defines nine assessment elements for CPT 99483, plus a written care plan. The builder takes you through each one, shows you what is still missing before you sign, and assembles the care plan in CMS order.

You make every clinical decision · Built by a physician (MBBS, PhD)

Start a 99483 care plan →See what you export

No account needed to start · First export free · ~$260 per 99483 (varies by locality)

Not ready to build one now? Get the documentation checklist or create a free account.

What Medicare requires

Nine assessment elements and a written plan.

Each element is a section in the builder. Leave one out and the builder shows it as missing, so you find the gap before you sign, not when the claim comes back.

CPT 99483 · required elementstracked live in the builder
  • Cognition-focused evaluation with pertinent history and examination
  • Medical decision making of moderate or high complexity
  • Functional assessment (ADL and IADL), including decision-making capacity
  • Standardized dementia staging (FAST or CDR)
  • Medication reconciliation and high-risk medication review
  • Neuropsychiatric and behavioral screening with a standardized instrument
  • Safety evaluation for the home and motor vehicle operation
  • Caregiver identification, knowledge, needs, and social supports
  • Advance care planning and palliative care needs
  • The written care plan, shared with the patient and caregiver
Start a 99483 care plan →
Pre-visit intake

The independent historian, captured before the visit.

99483 requires an independent historian. Send the caregiver a secure form ahead of the appointment; their history flows straight into the assessment, so the required element is already captured when you sit down.

Send a secure link

The caregiver gets a private form link. No login for them, and no health detail in the message itself.

They complete it pre-visit

Functional, behavioral, and safety history, supplied by the person who knows the patient best.

It fills your 99483

Responses pre-populate the assessment and satisfy the required independent historian element.

Available once you sign in, from the patient’s page.

What you export

A written care plan you can defend.

Not a transcript. A structured PDF in CMS order: findings in plain language, recommendations with a named responsible party, referrals, and a follow-up schedule. Your staff drops it into the chart; the family gets their copy.

cognitive-care-plan_sample.pdf Sample
Cognitive Assessment & Care Plan
Patient: redactedDOB: redactedDate of service: redactedProvider: redacted, MD
Summary of findings

Cognitive testing today shows impairment in short-term recall and executive function. Functional assessment indicates independence in basic ADLs, with support needed for finances and medication management. Dementia staging is consistent with mild dementia, corroborated by the independent historian. Depression screen negative.

InstrumentDomainResult
Mini-CogCognition2 / 5
Lawton-Brody IADLFunction5 / 8
FASTDementia stagingStage 4
PHQ-2Depression screenNegative
Care plan and recommendations
  • Medication management: transition to a weekly pill organizer, supervised by the caregiver. Clinic nurse to reconcile medications at each visit.
  • Safety: occupational therapy referral for a home safety evaluation. Driving re-evaluation recommended; counseling provided to the patient and family.
  • Caregiver support: education materials provided. Referral to a local caregiver support group.
Advance care planning and follow-up
  • Healthcare proxy documented. Directives to be revisited at follow-up.
  • Follow-up visit in 3 months to review function, safety, and directives, or sooner if behavior or safety changes.
  • This plan was reviewed with the patient and caregiver, and a copy was provided to each.
Electronically signed byredacted, MD
Dateredacted
2 more pages

Not running one today?

Get the CPT 99483 documentation checklist: the element set an auditor looks for, required and recommended, printable. We email it to you.

Want an account instead? Create one free. Prefer a walkthrough? Book a demo.

Start your first 99483 care plan.

Free to build, and no account needed to start. Sign in when you export; your first export is free. You review, edit, and sign every plan.

Start a 99483 care plan →