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