Medicare ADVISOR Q&A

PT Evaluation vs. Re-evaluation Billing

Question: My question is regarding billing for Medicare PT Evaluation vs. Re-evaluation. I have been given three versions:

1) You may only bill a Medicare patient for a PT evaluation if they have not been seen in physical therapy for the past three years. After that, the patient can only be billed for a re-evaluation, no matter the clinic or diagnosis.

2) You may only bill a Medicare patient for an initial PT evaluation if it is the first time they are seen at your practice. Thereafter you cannot bill an initial evaluation for three years no matter the diagnosis.

3) You can bill a Medicare patient for a PT evaluation for each NEW diagnosis. Thereafter you must bill a re-evaluation for the same diagnosis. I have not been able to find an answer on the PTA Website or the CMS (our Medicare provider) website.

Answer: They always say you can learn something new, and we are with this question. We have NEVER heard of any of those guidelines before. Needless to say, none of the above is true!

Medicare will pay for an initial evaluation when a patient is referred to you by a physician or non-physician practitioner. If the patient, while still being treated, has a referral for a new diagnosis (either from the existing referring source or a different one), then you re-evaluate the patient and create a new Plan of Treatment based on the re-evaluation and your current treatment plan. If the referral is from a different practitioner and neither of them is willing to sign off on a combined plan, then Medicare says you can have two separate plans with their own certification interval, but you combine the plans for your treatment and progress reports.

If you happened to have discharged a patient for one condition and then the next day, the patient comes back to you with a new diagnosis, you would perform a new evaluation and create the appropriate treatment plan; you can then bill Medicare for that service. There are absolutely no regulations that dictate timeframes between treatments for evaluation, once the patient has been discharged from care.

Following discharge, if the patient comes back to you with a referral for the same condition, you would perform a new evaluation. There is no guideline from Medicare to prevent this, but, you would really have to support the need for this new episode of care, especially if the timeframe was short from the prior discharge. Obviously, with the patient who has a deteriorating condition that can be exacerbated such as a neurological condition, this could happen within a close time span.

When we come to the patient who needs an update in their functional maintenance program, Medicare identifies in Chapter 15, §220.2, D. Maintenance Programs of the IOM Pub.100-02, Medicare Benefit Policy Manual "EXAMPLE: A Parkinson patient who has been under a rehabilitative physical therapy program may require the services of a therapist during the last week or two of treatment to determine what type of exercises will contribute the most to maintain the patient's present functional level following cessation of treatment. In such situations, the design of a maintenance program appropriate to the capacity and tolerance of the patient by the qualified therapist, the instruction of the patient or family members in carrying out the program, and such infrequent reevaluations as may be required would constitute covered therapy because of the need for the skills of a qualified professional."

Therefore in these instances, a re-evaluation would be the appropriate service to bill for updating the program.

Disclaimer: The answers that we provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.

Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. As an associate in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to Rehab Agencies. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass Website at or by phone at 954-720-4087.

Medicare Advisor Archives

In an Acute Care Setting, can a Treatment be billed right after an evaluation is performed especially if its documented as a distinct and separate event but just after the evaluation?

AJ May 09, 2016

We thank everyone for their interest and questions. Pauline Franko has retired from her Medicare Advisor column and will no longer be responding to questions.

Also, we remind our readers to check the date of publication of each article, which may contain information and guidelines that are no longer current.

Thank you.

Jonathan Bassett,  Editor,  ADVANCEMarch 28, 2016
King of Prussia, PA

While I have done much research and have found that the mandated reassessments (required to obtain G-codes) are a nonbillable item under CMS, what about discharge evaluations - are these billable items?

thanks in advance!


Kim PressleyMarch 28, 2016
Hendersonville, NC

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