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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Who Must Document the Evaluation?

Only a clinician (PT, OT, SLP) 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.

Medical Necessity for an Initial Evaluation 

Contents of an Evaluation
  • Diagnosis
  • 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 the Evaluation is the Only Service Provided

When the Evaluation Serves as the Plan of Care

Additional Assessments

Evaluations by Multiple Disciplines

Billing Tips for the Evaluation

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