We have received a number of questions lately as to when it is appropriate for a physical therapist to re-evaluate a patient. Please view the discussion and Medicare guidelines below.
Keep in mind that although these guidelines do not necessarily apply to your commercial patients, many commercial payers do basically follow Medicare guidelines to justify re-evaluations.
Under Medicare guidelines, a re-eval 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, Medicare 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 formal 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.