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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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Medicare Evaluations/Reevaluations FAQs

See our Medicare Evaluations and Medicare Re-evaluations sections for more detailed guidance.

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.

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.

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

About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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