Using Complexity-Based CPT Codes

How does one go about selecting the appropriate level of complexity for each patient evaluation? We’re glad you asked. This article details the four main evaluation complexity factors, along with a few sub-factors.

Complexity-based Coding Settings

You can make complexity-based questions in the documentation required in the Company Settings and at the insurance-level, learn more here.

Complexity-based Coding in Documentation

Review the complexity-specific fields in the WebPT EMR's evaluative notes. Click here to learn more.

Selecting the Right Level of Evaluation Complexity

1. Patient History

2. Depth and results of examination and use of standardized tests and measures

Expected progression
Objective findings

3. Clinical presentation

Status of the current condition
Mechanism of the current condition

4. Clinical decision-making

Goal establishment
Prognosis and probable outcome

Vocabulary

Really quick, before we jump into the defining characteristics of each complexity level, let’s define a few terms that’ll pop up throughout this post:

Body Regions: Refers to areas of the body, such as head, neck, back, lower extremities, upper extremities, and trunk.
Body Systems: Includes the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.
Body Structures: Refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
Body Functions: Refers to the physiological functions of body systems.

Now, let’s get into the nitty-gritty details associated with each level of evaluation complexity.