Placeholder Initial Exam for Non-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. 

Reasons to use a 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.
   

There are no mandatory fields for a non-Medicare patient on the  Objective tab. You may enter data, such as test results, from your original exam if desired. This information will carry forward into a progress note or re-examination.

On the  Assessment tab:

1. Complete the Patient Clinic Presentation field.            
   

There are no other required fields for a non-Medicare patient on the Assessment tab. You may enter data, such as problems and goals, from your original exam if desired. This information will carry forward into future notes. 

There are no mandatory fields for a non-Medicare patient on the  Plan tab. You may enter data, such as what treatment is to be provided, from your original exam if desired. This information will carry forward into future notes.

On the  Billing tab:

1. If you want to include treatment codes, check the Include Daily Note with this Initial Examination. If you do not want to include treatment codes, do not check the box and a Daily Note will not be generated.                                                      
   
2. Check the No Charges This Visit checkbox; this will apply a no-charge code that overrides the treatment codes. The treatment codes and the no-charge code will appear on the finalized note. Note: When you do the next note on the patient, you must de-select the No Charges This Visit checkbox; otherwise, that note will be no-charge as well.                                       
   
3. Click Finalize Initial Examination.