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What are the rules and regulations covering re-evaluations?

Vol. 17 •Issue 2 • Page 17
Coding Clues

What are the rules and regulations covering re-evaluations?

Q: The physical therapist that I work for submitted charges for 2 patients. One patient was a re-evaluation 2 (code 97002) and he charged $130. The second patient was a re-evaluation 4 (97002) and he charged $210.

How do I indicate these 2 different types of re-evaluations on the claims? Also, I know there needs to be some documentation to show change or a reason for a re-evaluation. Do I wait to see if the insurance company asks for this information? The provider is doing private practice in patients' homes.

A: CPT codes 97002 (physical therapy re-evaluation) and 97004 (occupational therapy re-evaluation) are considered service-based CPT codes and they are untimed. Regardless of the amount of time spent re-evaluating the patient, you should only bill 1 unit of the appropriate CPT code, unless a specific payer instructs you differently.

CPT codes are developed by the American Medical Association (AMA) and the majority of third party payers, including Medicare, follow the descriptors developed by the AMA. A small percentage of payers may take service-based, untimed codes and reimburse them in increments of 15 minutes, 30 minutes or 1 hour. In those rare cases, follow that specific payer policy to bill for these re-evaluation codes. You should bill the appropriate number of units based on the amount of time spent re-evaluating the patient.

Regarding supporting documentation, you don't need to submit information with the claim for Medicare and most third party payers. Exceptions to this are usually automobile and workers' compensation claims, where insurers generally want medical records submitted with a claim. If other payers question why you're billing re-evaluations, they can always request records prior to payment.

Q: I am a small rehab agency owner and for a long time I didn't bill for a re-evaluation at discharge because it always triggered an audit of the patient's entire chart or services.

During the past 3 years, we've been billing for re-evaluations only at the time of discharge. Should we bill for a re-evaluation for interim 700/701 forms, which Medicare requires at the end of each calendar month? Our intermediary also requires that these forms be attached to our hard copy claims.

A: According to CMS publication 100-102 (chapter 15, covered medical and other health services, section 220.3 C), a re-evaluation may be indicated due to new clinical findings, a patient's failure to respond to therapeutic interventions outlined in the plan of care or a significant change in the patient's condition. In addition, in Section 220 under the definition of re-evaluation, CMS states, "a re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement or decline or change in the patient's condition or functional status that was not anticipated in the plan of care for that interval."

Regarding billing for the purpose of completing a recertification, that's not a reason for performing and billing a re-evaluation if none of these reasons are present under national therapy guidelines from CMS. For instance, 1 Medicare contractor—Wisconsin Physician Services—states in its local coverage determination that Medicare policy requires recertification of a treatment plan by the attending physician every 30 days. In order to identify the need for continued treatment, and to comply with this regulation, it's considered reasonable and necessary for a therapist to perform a re-evaluation for recertification.

Keep in mind that beginning January 1, 2008 the initial certification for outpatient therapy services reimbursed under Medicare Part B benefits changed from 30 days to 90 days. This time frame should eliminate the majority of re-evaluations that were being billed because clinicians had to recertify therapy services.

In addition, CMS never required that 700/701 forms be used or completed at the end of every month. Prior to January 1, 2008, recertifications were required once every 30 calendar days for all settings (60 days for CORFs).

Rick Gawenda, PT, is director of physical medicine and rehabilitation at Detroit Receiving Hospital in Michigan. He's also the president of the American Physical Therapy Association section on health policy and administration. 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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