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Placeholder Initial Exam for Medicare Patient

Every case in WebPT must be opened with an Initial Examination. A  Placeholder IE is a no-charge visit and serves only to open the case in WebPT

Note: This is a guide for Medicare Patients. For non-Medicare Placeholder IE requirements, click here.

Reasons to use the placeholder:

  • You have already performed an IE for a patient either on paper or in different software and want to continue documenting with Daily Notes.
  • Your patient changes insurance mid-treatment and a new IE is not required by the new insurance.

Visits Prior to WebPT

If you are adding a patient to WebPT that has had prior visits, you will need to add the visit number to their case. The visit number is required for the Progress Note alerts and visit count field to display appropriately.  Note: Placeholder evaluations and no-charge visits do not count towards the visit count. 

  1. In the Patient's chart, select Patient Info.  
  2. In the Cases tab, add the case or edit the existing case. 
  3. Include the visit count, located at the bottom of the Case window. Click Ok to save. If you do not have this field, you’ll need to reach out to WebPT Support and have them turn it on for you.

    Note: A Placeholder Initial Evaluation will not count towards the total visit count. 
  4. Save the patient.

Creating the Placeholder

Now that we’ve added the patient’s prior visits, we can move on to creating the placeholder. On the Patient Records screen, choose  Add Initial Examination from the Patient Record Actions menu. 

SOAP Note Tabs: Requirements

On the  Subjective tab:

  1. Enter the original date of the IE. This date must pre-date any following Daily Notes.                                          
  2. Select Diagnosis and Treatment Diagnosis codes. Use the Copy Codes from Diagnosis button.                                   
  3. Select the Injury/Onset Date/Change of Status Date.                                                                      
  4. If complexity-based coding is required for your clinic, complete the Medical History Review section. For more information on complexity-based coding, click here

On the  Objective tab, you must include at least one Outcome Measurement Tool.

You may enter more data from your IE, such as test results, if you want the information to carry forward into a progress note or re-examination.

Note: If you do not include additional test information, we recommend performing a Re-examination instead of a Progress Note on the next evaluative visit so that you can select an evaluative profile. Whether you charge the re-eval code is up to you if you use the re-exam note. 

  1. Enter the Outcome Measurement Tool information on the IE. 

There is one mandatory requirement for a Medicare patient on the  Assessment tab.

  1. Complete the Patient Clinic Presentation field.                           
  2. You can enter additional data, such as problems and goals, from your original exam if desired. This information will carry forward into future notes.

On the  Plan tab:

  1. Select the Patient Status Update Only (Non-Billing Visit) checkbox.    
  2. Fill in Medicare Certification Frequency and Duration information.               
  3. You may enter additional data, such as what treatment is to be provided, from your original exam if desired. This information will carry forward into future notes.

You cannot enter  Billing information because the non-billing visit checkbox was selected on the Plan tab.

  1. Click Finalize Initial Examination.                                                                      
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