medicare physical therapy when to do re-evaluation

Under Medicare guidelines, a re-eval is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC (emphasis added).

Full Answer

When is a Medicare re-evaluation appropriate?

According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.” When medical necessity is supported, a re-evaluation (97164) is appropriate for:

When should a physical therapist choose between an initial Eval and re-evaluation?

So, to clear up some confusion, we put together a few common situations in which a physical therapist must choose between billing for an initial eval and a re-eval—along with our advice on how to handle those situations: A current patient develops a newly diagnosed, related condition.

What is a CPT re-evaluation for physical therapy?

 PT Re-evaluation (97164) The CPT description for a PT re-evaluation (97164) is in italics below: Re-evaluation of physical therapy established plan of care, requiring these components: 1. An examination including a review of history and use of standardized tests and measures is required; and

Does Medicare pay for outpatient physical therapy?

outpatient physical therapy. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B deductible applies.

How long do you have to wait to start a Medicare case?

What is 97164 in healthcare?

What is 97164 in a re-evaluation?

What is 97164 in medical?

Should you defer to the payer for a rotator cuff evaluation?

Can you re-evaluate after surgery?

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When do you use a re-evaluation code for physical therapy?

Use: Re-evaluation (97164) If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you'll need to complete a re-evaluation and create an updated plan of care.

How often does a PT have to see a Medicare patient?

The PT must recertify the POC “within 90 calendar days from the date of the initial treatment,” or if the patient's condition evolves in such a way that the therapist must revise long-term goals—whichever occurs first.

How often should therapy Maintenance be reassessed?

Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the needed therapy service and functionally reassess the patient at least every 30 days.

In which situation is a billable re-evaluation appropriate?

When medical necessity is supported, a re-evaluation is appropriate and is separately billable for: A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA.

What is plan of care in physical therapy?

The POC consists of statements that specify the anticipated goals and expected outcomes, predicted level of optimal improvement, specific interventions to be used, and proposed duration and frequency of the interventions. The POC describes the specific patient/client management for the episode of physical therapy care.

What is a progress note in physical therapy?

A therapy progress note updates a prescribing physician on their patient's current status towards their rehab goals. This kind of note can also take the place of a daily note, since it follows the standard SOAP formula for daily documentation.

What is the CPT code for physical therapy re-evaluation?

97164 - Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional ...

What is meant by maintenance therapy?

Maintenance Therapy - Glossary Ans : Treatment that is given to help a primary (original) treatment keep working. Maintenance therapy is often given to help keep cancer in remission.

What is a functional maintenance program?

Therapists have the responsibility of helping our clients, even when experiencing injury and chronic illness, maintain their functional abilities. Functional Maintenance Programs are designed to optimize and maintain a client's performance after they are discharged from therapy.

What is difference between progress note and re evaluation?

Re-evaluations are not routine and shouldn't be billed routinely. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).

How often do you need a progress note?

once every 10 treatment visitsProgress Reports need to be written by a PT/OT at least once every 10 treatment visits.

Does Medicare cover G0283?

Stimulation delivered via electrodes should be billed as G0283. The charges for the electrodes are included in the practice expense portion of code G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality.

Physical Therapy Evaluation Reference Table 97161 97162 97163

Physical Therapy Evaluation Reference Table CPT© Code 97161 97162 97163 Required Components (all are required in selecting evaluation level) History no personal factors and/or comorbidities X 1-2 personal factors and/or comorbidities X 3 or more personal factors and/or comorbidities X Examination of body system(s) (elements include body structures and functions,

When to Charge for a PT/OT Re-evaluation | PT Management

We often receive questioned as to when a re-evaluation is necessary (and billable). Therapists are understandably uncertain as to when a re-evaluation can be billed because of conflicting terminology and confusion with “reassessment” requirements in PT and OT Acts.

11 Part B Billing Scenarios for PTs and OTs - CMS

Reviewed 9/2009 billed by either the PT or the OT, but not both. Similarly, if two therapy assistants provide services to the same patient at the same time, only the service of one therapy assistant can be

General Information

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Article Guidance

Therapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

How long do you have to wait to start a Medicare case?

Unfortunately, there isn’t a whole lot of solid guidance on this scenario. However, in the case of Medicare, if 60 days have passed, you must start the case over with an initial evaluation. That’s because Medicare automatically discharges a case when no claims have been submitted for 60 days. But again, this rule specifically applies to Medicare. For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate.

What is 97164 in healthcare?

Use: Re-evalua tion (97164) If, during the course of care, you determine that the original plan isn’t having the intended effect on the patient, you may feel it necessary to change the plan of care. In this case, you would perform—and bill for—a re-evaluation.

What is 97164 in a re-evaluation?

Use: Re-evaluation (97164) This could include any improvement, decline, or other change in functional status that: you didn’t anticipate when you originally established the plan of care, and. requires further evaluation to ensure the best therapy outcomes.

What is 97164 in medical?

Use: Re-evaluation (97164) If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you’ll need to complete a re-evaluation and create an updated plan of care.

Should you defer to the payer for a rotator cuff evaluation?

For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate . Example: You treat a 30-year-old carpenter for right rotator cuff weakness and discharge him or her from care.

Can you re-evaluate after surgery?

Re-evaluations also may be appropriate for patients who received therapy treatment prior to surgery and then returned for additional rehabilitation after surgery. The catch in this situation is that some commercial payers may consider the post-op treatment period a new episode of care, in which case you’d need to use an evaluation code.

What is the AMA CPT?

In sum, the AMA CPT descriptions provide the basics of when a re-evaluation may be billed and what must be included in a PT and OT re-eval. You should note that Medicare and other payers can and sometimes do impose additional conditions that must be met to be paid for a reevaluation.

What is a re-evaluation in Medicare?

The AOTA describes a re-evaluation as the “reappraisal of the patient’s performance and goals to determine the type and amount of change that has taken place. Medicare and other third-party payers may have particular rules about when a re-evaluation may be reimbursed.

Why are therapists uncertain about re-evaluation?

Therapists are understandably uncertain as to when a re-evaluation can be billed because of conflicting terminology and confusion with “reassessment” requirements in PT and OT Acts. To determine if and when a re-evaluation is billable, we need to look at all of the following rules:

What is the time required for a standardized patient assessment?

2. Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.

How long is 97164?

Typically, 20 minutes are spent face-to-face with the patient and/or family. This means that every time 97164 is billed, regardless of the payer, the elements listed as 1 and 2 above must be completed and documented. The time period of 20 minutes is only mentioned as being typical but is not required.

Is a re-evaluation required by Medicare?

Under Medicare guidelines, a re-evaluation is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC (emphasis added).

Does Tricare have a re-eval?

The major commercial payers and Tricare do not have any unique guidance regarding re-evals. Their PT/OT policies basically include the AMA’s CPT descriptions for 97164 and 97168 if they include anything at all. Medicare’s more restrictive re-evaluation rules do not necessarily apply to these payers.

What is Medicare approved amount?

Medicare-Approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B deductible applies.

What is part B in physical therapy?

Physical therapy. Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. outpatient physical therapy.

How long does it take for Medicare to recertify?

And even when things do go according to plan, Medicare requires recertification after 90 days of treatment. If you’re a WebPT Member, you can use WebPT’s Plan of Care Report to identify which plans of care are still pending certification as well as which ones require certification—before those 90 days are up.

What is a POC in therapy?

The Plan of Care (POC) Based on the assessment, the therapist then must create a POC —complete with treatment details, the estimated treatment time frame, and the anticipated results of treatment. At minimum, Medicare requires the POC to include: Medical diagnosis. Long-term functional goals.

How long does it take to sign a POC?

Medicare requires that a licensed physician or nonphysician practitioner (NPP) date and sign the POC within 30 days. To make things easier, though, the certifying physician doesn’t have to be the patient’s regular physician—or even see the patient at all (although some physicians do require a visit).

How long does it take for Medicare to discharge a patient?

Medicare automatically discharges patients 60 days after the last visit. Unfortunately, if the patient has been discharged, then you will need to perform a new initial evaluation. If you do not live in a direct access state, then you will also need to to get the physician's signature on the patient's new POC.

What is the evaluation of a licensed therapist?

Before starting treatment, the licensed therapist must complete an initial evaluation of the patient, which includes: Objective observation (e.g., identified impairments and their severity or complexity) And, of course, all of this should be accounted for you in your documentation.

How long do you have to recertify a patient?

If this occurs, you'll need to obtain a recertification from the physician. And no matter what, you must obtain a recertification after 90 days. So, to answer your first question, no—there is no rule that you must send the patient back to the referring physician after 10 visits.

How often do you need a progress note for Medicare?

Currently, Medicare only requires a progress note be completed, at minimum, on every 10th visit. I hope that helps!

How long is a Medicare certification?

The length of the certification period is the duration of treatment, e.g. 2x/week for 8 weeks. In this example the end date of the certification period is 8 weeks, to the day, from the initial evaluation date. In 2008 Medicare changed the requirement for the maximum duration of each plan of care. The maximum length of time any certification period ...

How long can a Medicare plan of care be certified?

The maximum length of time any certification period used to be 30 days, however now it can run up to 90 days.

How to get a POC?

A POC being sent for certification must contain ALL of the following elements to meet the requirements: 1 The date the plan of care being sent for certification becomes effective (the initial evaluation date is acceptable) 2 Diagnoses 3 Long term treatment goals 4 Type, amount, duration and frequency of therapy services 5 Signature, date and professional identity of the therapist who established the plan 6 Dated physician/NPP signature indicating either agreement with the plan or any desired changes.

What are the requirements for a POC?

A POC being sent for certification must contain ALL of the following elements to meet the requirements: The date the plan of care being sent for certification becomes effective (the initial evaluation date is acceptable) Diagnoses. Long term treatment goals. Type, amount, duration and frequency of therapy services.

What happens if you don't comply with Medicare?

If, in the course of the audit, they find you do not have the Certifications/Re-certifications, if appropriate, included in the chart they can deem your care for that patient as not meeting the medical necessity or the requirement to be under a physician’s care. In that case Medicare can decide that all the care for these patients should not have been carried out and can ask for all payments plus interest and a penalty to be returned to them. This can come to a significant amount of money, especially if it occurs in a number of patient’s charts.

Can a physical therapist establish a POC?

CMS says either a physician/NPP or physical therapist can establish the POC but if the therapist does it then physician/NPP must approve of the plan. That’s where the signing off on the plan of care by the physician/NPP affirms that the patient is under their care and they agree with the plan.

Can you claim all your patients require the maximum time allowed?

Claiming all your patients require the maximum time allowed may trigger an audit of your documentation. CMS recommends you set the duration for your certifications at your best estimate of the length of time it will take your patient to achieve their goals.

What is a patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in

A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.

How often should a therapist bill a progress note?

Re-evaluations are not routine and shouldn’t be billed routinely. Progress notes are routine and are completed at every 10th visit or every 30 days ...

Is a re-evaluation considered medically necessary?

According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.”. When medical necessity is supported, a re-evaluation (97164) is appropriate for: ...

How long do you have to wait to start a Medicare case?

Unfortunately, there isn’t a whole lot of solid guidance on this scenario. However, in the case of Medicare, if 60 days have passed, you must start the case over with an initial evaluation. That’s because Medicare automatically discharges a case when no claims have been submitted for 60 days. But again, this rule specifically applies to Medicare. For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate.

What is 97164 in healthcare?

Use: Re-evalua tion (97164) If, during the course of care, you determine that the original plan isn’t having the intended effect on the patient, you may feel it necessary to change the plan of care. In this case, you would perform—and bill for—a re-evaluation.

What is 97164 in a re-evaluation?

Use: Re-evaluation (97164) This could include any improvement, decline, or other change in functional status that: you didn’t anticipate when you originally established the plan of care, and. requires further evaluation to ensure the best therapy outcomes.

What is 97164 in medical?

Use: Re-evaluation (97164) If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you’ll need to complete a re-evaluation and create an updated plan of care.

Should you defer to the payer for a rotator cuff evaluation?

For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate . Example: You treat a 30-year-old carpenter for right rotator cuff weakness and discharge him or her from care.

Can you re-evaluate after surgery?

Re-evaluations also may be appropriate for patients who received therapy treatment prior to surgery and then returned for additional rehabilitation after surgery. The catch in this situation is that some commercial payers may consider the post-op treatment period a new episode of care, in which case you’d need to use an evaluation code.

A Current Patient Develops A Newly Diagnosed, Related Condition.

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A Current Patient Develops A Newly Diagnosed, Unrelated Condition.

A Patient Undergoes Surgery Mid-Plan of Care.