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Can you receive Medicare reimbursement for a re-evaluation?

Vol. 16 •Issue 3 • Page 13
Coding Clues

Can you receive Medicare reimbursement for a re-evaluation?

Q: A colleague informed me that his billing agency gets him reimbursed from Medicare for a re-evaluation. Can you explain how this is possible?

A: Medicare has always reimbursed for re-evaluations that are provided by a physical therapist and/or an occupational therapist, as long as it was medically necessary and supported by documentation. Criteria for a re-evaluation may include:

  • a professional assessment that indicates a significant improvement, decline or change in the patient's condition or functional status that wasn't anticipated in the plan of care for that interval

  • new clinical findings

  • failure of the patient to respond to treatment outlined in a current plan of care

  • determining if goals have been met at a planned discharge, or for physician use or for the setting where treatment will continue.

    If you provide a re-evaluation on the same day as treatment, a physical therapy or occupational therapy re-evaluation is considered a component of the more comprehensive treatment CPT code. As a result, you're required to append modifier -59 to the re-evaluation code on the claim form in order to be reimbursed. Documentation must support the medical necessity of a re-evaluation and show that it was provided at a separate and distinct time from treatment interventions.

    For the CMS reference, go to and read the definition of re-evaluation in section 220 and the criteria for a re-evaluation in section 220.3.C.

    Rick Gawenda, PT, is director of physical medicine and rehabilitation at Detroit Receiving Hospital in Michigan. He conducts national seminars on coding and reimbursement, along with other topics. If you have a tough coding issue you can't crack, e-mail To read more coding suggestions, go to and click on the Coding Clues tool bar.


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