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Therapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians i.e., a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP).
Therapy evaluation, re-evaluation, and formal testing codes can only be billed when the medical record supports the completion of a medically necessary comprehensive evaluation or formal test. Documentation must support that the service was needed based on the patient’s current clinical status or condition. Medicare does not reimburse for services related solely to workplace skills and activities. Additional evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patient’s therapy progression. Note that routine continuous assessment of the patient’s expected progress in accordance with the plan of care is not separately reimbursable as a re-evaluation or formal testing service.
Initial Evaluations – (i.e., CPT ® 97161-97163,97165-97167)
Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline i.e., physical therapist (PT), and/or occupational therapist (OT), and/or SLP, will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for:
• A new patient who has not received prior therapy services.
• A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:
- Patient no longer significantly benefited from ongoing therapy services or;
- Patient no longer required therapy services for an extended period of time or;
- Patient experienced a significant change in medical status that necessitated discharge.
• A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition. Example: A patient is currently receiving treatment following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.
For additional information, see the attached “Medical Necessity of Therapy Services” article in the Related Coverage Documents link below.
Re-Evaluations– (i.e., CPT®97164, 97168)
Re-evaluations are separately reimbursable when the medical record supports that the patient’s clinical status or condition required the additional evaluative service. When medical necessity is supported, a re-evaluation is appropriate and is separately billable for:
• A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
• A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.
Note that routine continuous assessment of the patient’s expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a re-evaluation. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services an is included in services and procedures.
Formal Testing (i.e., CPT®97750, 95851-95852)
Formal testing services are considered inclusive (not separately reimbursable) when they are provided on the same day as an initial evaluation or re-evaluation service. Formal testing services are separately reimbursable when the medical record supports that the patient’s clinical status or condition required the additional testing service. Formal testing services should not be billed using therapy service or procedure codes. When medical necessity is supported a formal test is appropriate and is separately reimbursable when documentation supports the completion of a formal, date signed, distinctly identifiable findings report which includes:
• Testing and/or measurement results with comparative values for specific standardized grading scales.
• Provider’s interpretation of results.
• Support of how the findings were incorporated into the therapy plan of care, when applicable.
Note that routine continuous assessment of the patient’s expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a formal test. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services and is included in services and procedures.
Sources:
• Current Procedural Terminology (CPT) Manual
• CMS Internet Only Manual (IOM), Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 220.3.5(A), 230.1.
• IOM, Medicare Benefit Policy Manual,, Publication 100-02, Chapter 16, Section 150
We often receive questioned as to when a re-evaluation is necessary (and billable). Therapists are understandably uncertain as to when a re-evaluation can be billed because of conflicting terminology and confusion with “reassessment” requirements in PT and OT Acts.
To determine if and when a re-evaluation is billable, we need to look at all of the following rules:
The AMA’s CPT descriptions and guidelines for 97164 (PT re-eval) and 97168 (OT re-eval)
Medicare rules on when a re-evaluation is justified and billable
Non-Medicare payer rules on when a re-evaluation is justified and billable
State PT and OT supervision rules requiring therapists to do periodic “reassessments” AMA CPT Guidance
PT Re-evaluation (97164) The CPT description for a PT re-evaluation (97164) is in italics below: Re-evaluation of physical therapy established plan of care, requiring these components:
1. An examination including a review of history and use of standardized tests and measures is required; and
2. Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome
Typically, 20 minutes are spent face-to-face with the patient and/or family.
This means that every time 97164 is billed, regardless of the payer, the elements listed as 1 and 2 above must be completed and documented. The time period of 20 minutes is only mentioned as being typical but is not required. This is not a timed code.
The AMA CPT Assistant, which provides explanations of how CPT codes should be used, includes the following example of a PT re-eval:
A 62-year-old male with low back pain presents for a physical therapy re-evaluation on his eighth visit of his episode of care. The patient had been making progress toward his goals. At his last visit, he reported a reduction in pain from 6/10 to 1/10 and an ability 2 to return to driving and light exercise. However, at this visit, he presents with an increase in pain to 8/10 and describes radiation of pain and sensory loss in the right posterior leg and lateral foot. He is unable to sit for more than 3 minutes. The updated patient medical history is reviewed and current medications are confirmed. The patient’s self-reported and/or performance-based measurement outcome tool is reviewed. The examination during re-evaluation includes measurement of gross range of motion as well as segmental mobility, neurologic status, and muscle strength. The patient’s and/or family/caregiver’s questions are answered as appropriate throughout the re-evaluation. Interpretation of the patient’s response to tests and measures is recorded to assist with updating the plan of care.
OT Re-evaluation (97168)
The CPT description for an OT re-evaluation (97168) is in italics below: Re-evaluation of occupational therapy established plan of care, requiring these components:
An assessment of changes in patient functional or medical status with revised plan of care;
An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
A revised plan of care. A formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
The AMA CPT Assistant includes the following explanation of an OT re-eval:
Code 97168 is used to report occupational therapy re-evaluation that is based on an established and ongoing plan of care. This is in contrast to the evaluation codes that include development of a plan of care. The AOTA describes a re-evaluation as the “reappraisal of the patient’s performance and goals to determine the type and amount of change that has taken place. Medicare and other third-party payers may have particular rules about when a re-evaluation may be reimbursed. The CPT code set guidelines only describe the components required to report the service. For example, the evaluations codes and the re-evaluation code describe typical time of 30 minutes for face-to-face interaction with the patient and/or family. Again, this is not to be considered a requirement or a limit on time.
In sum, the AMA CPT descriptions provide the basics of when a re-evaluation may be billed and what must be included in a PT and OT re-eval. You should note that Medicare and other payers can and sometimes do impose additional conditions that must be met to be paid for a reevaluation.
Medicare Guidelines
CMS has published fairly extensive guidance as to when a re-evaluation is called for and payable. This guidance is included in Medicare Benefit Policy Manual Ch 15, Section 220.
Under Medicare guidelines, a re-evaluation is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC (emphasis added). Along these same lines, CMS guidance regarding re-evals further provides that:
Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.
A re-evaluation is not a routine, recurring service, but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
A re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.
Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the POC.
A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.
A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
A re-evaluation should not be routinely required before every progress report but may be appropriate when an assessment suggests changes not anticipated in the original POC.
In addition, the Medicare manual includes the following scenario where a patient on a maintenance program needs intermittent review and possibly a new or revised maintenance program.
EXAMPLE: A patient who has a progressive degenerative disease is performing the activities in a maintenance program established by a therapist with the assistance of family members. The program needs to be re-evaluated to determine whether assistive equipment is needed and to establish a new or revised maintenance program to maintain function or to prevent or slow further deterioration. Intermittent re-evaluation of the maintenance program would generally be covered as this is a service that requires the skills of a therapist. Should the therapist conducting the re-evaluation determine that the program needs to be revised, these services would generally be covered.
In sum, Medicare does not allow for routine re-evals as the patient progresses through his or her POC. For example, a re-evaluation should not be charged for every 10th visit requiring a progress note unless the assessment indicates changes not anticipated in the original POC.
Non-Medicare Payer Rules
The major commercial payers and Tricare do not have any unique guidance regarding re-evals. Their PT/OT policies basically include the AMA’s CPT descriptions for 97164 and 97168 if they include anything at all.
Medicare’s more restrictive re-evaluation rules do not necessarily apply to these payers. Instead, therapists can rely on the AMA’s descriptions of 97164 and 97168 (see above) to determine whether a re-evaluation is indicated and billable. While Medicare rules are more restrictive than the CPT descriptions, a change in patient condition indicating the necessity for a change in the POC is still required per the AMA.
State PT/OT Acts
Many state PT and OT Acts and related regulations require therapists who are supervising assistants and aides to periodically reassess the patient’s progress. For example, the North Carolina PT rules state that:
If a physical therapist assistant or physical therapy aide is involved in the patient care plan, a physical therapist shall reassess a patient every 60 days or 13 visits, whichever occurs first.
These requirements to periodically reassess the patient are supervisory rules and do not in and of themselves indicate that a re-evaluation should be charged for every reassessment. Therapists should instead look to the Medicare rules for Medicare patients or the AMA CPT rules for non-Medicare patients to determine whether the PT or OT re-evaluation code can be billed as discussed above.
