Posted on October 12, 2022

See our Medicare PT/OT/SLP Evaluations Page for more information.

Who can perform a therapy evaluation?

Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.

A clinician means either a physician or a physical, occupational, or speech therapist.

Can an assistant participate in an evaluation?

A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.

When does an evaluation need to be performed?

An evaluation must be completed prior to beginning of treatment.

Can an evaluation and treatment be performed on the same visit?

Yes. Once the evaluation has been completed, the therapist may start treatment.

What must be included in the evaluation?

A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.

Results of one of the following four measurement instruments are recommended, but not required:

• National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association
• Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)
• Activity Measure – Post Acute Care (AM-PAC)
• OPTIMAL by Cedaron through the American Physical Therapy Association

 - Documentation supporting illness severity or complexity.

 - Documentation supporting medical care prior to the current episode.

 - Documentation required to indicate beneficiary health related to quality of life.

 - Documentation required to indicate beneficiary social support.

 - Documentation required to indicate objective, measurable beneficiary physical function.

When is an evaluation medically necessary?

A new patient who has not received prior therapy services.

A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:

• Patient no longer significantly benefited from ongoing therapy services or;
• Patient no longer required therapy services for an extended period of time or;
• Patient experienced a significant change in medical status that necessitated discharge.

A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition.

Is an evaluation different from an assessment?

An assessment is separate from evaluation, and is included in services or procedures, (it is not separately payable). The term assessment as used in Medicare manuals related to therapy services is distinguished from language in Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment, which may be payable).

Assessments may only be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s).

The assessment determines, e.g., changes in the patient's status since the last visit/treatment day and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated. Routine weekly assessments of expected progression in accordance with the plan are not payable as re-evaluations.

When is a screening more appropriate than an evaluation?

Screening may be more appropriate than evaluation in some circumstances. For example, a patient develops an acute lateral epicondylitis from painting. The patient seeks physician attention who subsequently recommends that the patient see an occupational therapist. By the time the patient sees the PT/OT/SLP, she presents without any pain and has resumed all normal functional activities.

Completing a screening interview of this patient should lead the therapist to determine that an PT/OT/SLP evaluation and treatment would not be medically necessary.

• A screening is the gathering of information to determine the need for further evaluation by the clinician. The screening process may include a review of the patient’s medical record, a patient interview and observation of the patient.
• Routine screening is not a billable service. Although some regulations and state practice acts require screening evaluations at specific intervals (such as at admission to a nursing home, or quarterly during the patient’s stay), for Medicare payment, evaluations must meet Medicare coverage guidelines.

References

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services §220.3

Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067

Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing: A52773

Outpatient Physical and Occupational Therapy Services: L34049