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Who Must Document the Evaluation?
Only a clinician (PT or OT) may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.
The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits. It is appropriate that treatment begins when a plan is established.
The time spent in evaluation shall not also be billed as treatment time. Evaluation minutes are untimed and are part of the total treatment minutes, but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes.