There are PDF Occupational Therapy Evaluations as described in the code.

When a re-evaluation is needed, we are often questioned.Because of conflicting terminology and confusion with "reassessment" requirements, therapists are unsure of when a re-evaluation can be billed.

When a re-evaluation is billable, we need to look at all of the following rules.

State rules require therapists to do periodic reassessments.

The re-evaluation of physical therapy established plan of care requires these components.

1.A review of history and use of standardized tests and measures is required.

2.Revised plan of care using a standardized patient assessment instrument.

Every time 97164 is billed, the elements listed above must be completed and documented.The time period of 20 minutes is not required.This isn't a timed code.

The following example of a re-eval is included in the explanation of how the codes should be used.

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 was making progress.He reported a reduction in pain and an ability to return to driving and light exercise after his last visit.At this visit, he presents with an increase in pain to 8/10 and a description of pain and sensory loss in the right leg and foot.He can't sit for more than 3 minutes.Current medications are confirmed after the updated patient medical history is reviewed.The outcome tool used by the patient is reviewed.Gross range of motion, segmental mobility, neurologic status, and muscle strength are measured during the re-evaluation.The questions of the patient and family are answered as appropriate during the re-evaluation.The plan of care is updated with the interpretation of the patient's response to tests and measures.

The re-evaluation of occupational therapy established plan of care is required by the CPT description.

An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals.

A revised plan of care.When there is a documented change in functional status or a significant change to the plan of care, a formal re-evaluation is performed.

Code 97168 is used to report occupational therapy re-evaluation that is based on an ongoing plan of care.Development of a plan of care is included in the evaluation codes.A re-evaluation is the appraisal of the patient's performance and goals to determine the type and amount of change that has taken place.Third-party payers may have rules about when a re-evaluation can be paid for.The components required to report the service are only described in the guidelines.A typical time of 30 minutes for face-to-face interaction with the patient and/or family is described in the evaluations codes.This is not a requirement or limit on time.

The basics of when a re-evaluation can be billed and what must be included are provided in the descriptions.Medicare and other payers can sometimes impose additional conditions that must be met to be paid for a reevaluation.

When a re-evaluation is called for and payable has been published by the Centers for Medicare and Medicaid Services.This guidance can be found in the Medicare Benefit Policy Manual.

If the therapist determines that the patient has had a significant improvement, decline, or other change in his or her condition or functional status that was not anticipated in the POC, then a re-evaluation is medically necessary.The same lines are followed by the guidance regarding re-evals from the Centers for Medicare and Medicaid Services.

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 a service that focuses on evaluation of progress toward current goals, making a professional judgement about continued care, modifying goals and/or treatment or terminated services.

If the documentation supports the need for further tests after the initial evaluation, a re-evaluation is not covered.

New clinical findings, a significant change in the patient's condition, or failure to respond to therapeutic interventions are some of the indications for a re-evaluation.

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 may be appropriate prior to planned discharge.

A re-evaluation focuses on evaluation of progress toward current goals and making a professional judgement about continued care, modifying goals, and/or treatment.

When an assessment suggests changes not anticipated in the original POC, a re-evaluation should not be required before every progress report.

There is a scenario in the Medicare manual where a patient on a maintenance program may need intermittent review.

A patient with a progressive disease is performing activities in a maintenance program established by a therapist with the assistance of family members.To establish a new or revised maintenance program to maintain function, the program needs to be reexamined.Intermittent re-evaluation of the maintenance program is a service that requires the skills of a therapist.The services would be covered if the program needs to be revised.

Medicare does not allow for routine re-evals as the patient progresses through his or her point of contact.If the assessment indicates changes not anticipated in the original POC, a re-evaluation should not be charged for every 10th visit.

Tricare and the major commercial payers don't have any specific guidance on re-evals.If they include anything at all, their policies include the AMA's descriptions for 97164 and 97168.

The re-evaluation rules do not apply to these payers.The descriptions of 97164 and 97168 can be used to determine whether a re-evaluation is indicated and billable.There is still a need for a change in the patient condition in order for Medicare rules to be more restrictive.

Many state laws require therapists who are supervising assistants and aides to periodically assess the patient's progress.The North Carolina rules state that.

If a physical therapist assistant or physical therapy aide is involved in the patient care plan, a patient will be assessed every 60 days or 13 visits, whichever occurs first.

The requirements to periodically reassess the patient do not indicate that a re-evaluation should be charged.The Medicare rules for Medicare patients should be used by therapists to determine if the OT re-evaluation code can be billed.

One of the largest databases of outpatient provider productivity, visit and payment information, with more than 3 million visits.

Over the course of a month, we add data from tens of thousands of visits to the physical and hand therapy benchmark database.