When to Bill For a Reevaluation

April 4, 2016
Rick Gawenda

I am frequently asked when is it appropriate to bill a reevaluation to an insurance carrier? Is it appropriate to bill when I am doing a Progress Report on a patient? Is it appropriate to bill for the purpose of completing a recertification on a Medicare patient? Is it appropriate to bill on the day I am also reporting the functional limitation reporting G-codes on a Medicare patient?

In this article, I will answer the above 4 questions and provide you with the main criteria when a reevaluation would be appropriate to perform on a patient and bill to the insurance carrier, including the Medicare program. Lets start with the criteria of when a reevaluation is appropriate to perform and bill to an insurance carrier.

A reevaluation may be considered reasonable and necessary in the following situations:

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  1. Thank you for this information! It’s nice to know I was teaching my staff the right things. But, I have found very little on the last question – so I’m looking forward to learning more in the next article.

    1. Thank you! If you are referring to the last question about Progress Reports and how to account for that time, next Tuesday’s article will answer that question for you and others.

  2. is it appropriate to bill for a reeval when a patient is hospitalized for a medical condition where there is not a change in function when they return for PT treatment?

  3. How about when a patient stays out for two or more weeks with an illness, would you have to “Re-Evaluate” and then once the patients function is determined then decide whether to bill the re-eval or not? (i.e. function has changed, bill it, the function has not changed, don’t bill it.

    1. Just because a patient does not attend therapy for 2 weeks does not mean a reevaluation is also warranted. The illness may have had nothing to do with why the patient was attending therapy services. The key is was there a significant change in the patient’s condition that you were not anticipating to see today and/or did it require a significant change in their plan of care.

  4. In the Medicare guidelines it states re-evaluation is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. It states a re-eval may be appropriate prior to a planned discharge for the purpose of determining whether goals have been met. So could it not be appropriate to charge a re-evaluation at DC if I am using my professional judgment to determine if goals have been met and whether the patient would need to continue with treatment or be discharged? And could that not also apply to a re-certification if you are using your professional judgment to determine if goals have been met and services should be terminated or if services should be continued? Thanks

    1. It could be appropriate at a planned DC if you needed to do a reevaluation to determine if you should DC or not. In my experience, that is usually not the case. During follow-up treatment sessions, we are doing ongoing assessments and usually know what visit will be the patient’s last. I do not recommend billing a reevaluation at every DC. Keep in mind, reevaluations are not the norm. Just because you are doing a recertification is not a reason to do a reevaluation unless you are making significant changes to the patient’s plan of care due to functional status change of the patient or perhaps they are not progressing as expected.

  5. Medicare automatically discharges a reporting episode when it has been 60 or more calendar days since the last recorded DOS.

    If a patient returns to PT more than 60 calendar days from their last appt, is it appropriate to perform a Re-Eval (as opposed to an Initial Eval) if they are coming back for the same exact DXs?

    1. Each patient case scenario is unique and the therapist would need to determine what is most appropriate to perform and bill.

  6. If you’re seeing a patient for pre-hab (i.e. pre-ACL or pre-TKA) then would a re-evaluation be appropriate as long as you do not discharge them prior to surgery? Is there a certain length of time between end of pre-hab and surgery that is reasonable to keep the chart open? I believe Medicare considers a case discharged if >60 days pass from the last appointment date.

    1. If you are seeing them for pre-hab for the same joint that they then have a joint replacement and return to therapy, in my opinion would be a re-evaluation.