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Medicare Evaluations and Reevaluations for PT and OT

9 Sep 2019 5:11 PM | Zachary Edgar (Administrator)

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.

When?

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

Reevaluations

  • Who may Perform a Reevaluation?
  • Role of the Assistant
  • When can a Reevaluation be Performed?
  • Reimbursement
  • Content of the Reevaluation
  • Billing for a Reevaluation
  • Documentation

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