Selecting an Evaluation Code Complexity Level

Learn how to use the documentation fields related to the required complexity-based coding for PT and OTs. Once properly completed, the billing tab will provide a suggested evaluation code and explanation. 

Complexity-based evaluation codes will automatically appear in the SOAP note for any date of service 1/1/2017 or after. These fields will appear on all evaluative note types (Initial Exam, Progress Note, Discharge Summary), so if complexity-based coding was not completed for a patient's Initial Examination, it will still be required for Progress and Discharge Summary note types.

You can update your company's settings for complexity-based coding. 

If you are currently treating a patient that had an Initial Examination prior to 8/16/17, you will need to complete complexity-based coding for the Progress and Discharge Summary note types.

For patients who have an Initial Examination with completed complexity-based coding (dated 8/17/17 or later), the complexity fields will automatically be populated in Progress and Discharge Summary note types based on the selections made in the Initial Examination. 

Subjective Tab

In the subjective tab, there are additional fields in the Complicating/Personal Factors area to help break down the treatment complexity level related to the characteristics described in Using Complexity-Based CPT Codes.

Right below that section is Medical History Review—a required field—which allows you to use the factors selected above to make a determination on the complexity, focusing solely on the patient's medical history. Once you make a selection, the red required field notification will disappear. 

Assessment Tab

On the Assessment Tab, there is a required field for Clinic Presentation under the Assessment/Diagnosis text box. Once you make a selection, the red required field notification will disappear. 

Billing Tab

Both of the required fields above must be completed before the note can be finalized. Once both fields are completed, the suggested evaluation code is noted by the underlined text and an explanation will appear on the Billing tab.

The suggested code will be determined based on the lowest level of complexity selected between the Medical History Review and Clinical Presentation. If you did not properly complete any required field when attempting to finalize the note, an alert will appear notifying the user to correct it.

Remember, if complexity-based coding was not completed for a patient's Initial Examination, it will still be required for Progress and Discharge Summary note types. 

Additional resources can be found in the blue question mark next to each field.