When should I bill for a physical therapy re-evaluation (97002)?
This has been a hot topic in many billing and coding seminars, discussions, and forums as there seems to be a very common misunderstanding as to when a physical therapy re-evaluation should be performed and billed. With that being said, I wanted to take a brief moment to clarify that a re-evaluation is very different from a 10th visit progress note.
NOTE: Effective January 1, 2013, the progress note requirement was changed from every 30 days or 10th visit, whichever is less to solely every 10th visit.
A re-eval (97002) should be considered a “rare” occasion and billed only when there has been a “significant and unexpected change in the patient’s condition". Below are a couple great articles that provide additional support and clarification on this topic.
"Therapy re-evaluations are separately payable if the documentation shows significant and unexpected change in the patient’s condition that supports the need to perform a formal re-evaluation of the patient’s status. When a patient exhibits a demonstrable change in physical functional ability, a re-evaluation is covered to re-establish appropriate treatment goals and interventions. Reassessments are considered a routine aspect of intervention and are not billed separately from the charge for the intervention. Re-evaluations are not routinely covered for purposes of updating the plan of care".
Question: I work in an outpatient setting and when it's time to do a progress note, I was questioned by my boss as to why I didn't bill for the progress note as a re-evaluation. There were no additional MD orders, and this was strictly a 10th day visit progress note. What is the right way to bill in this case?
Answer: You were correct to not bill for a re-evaluation in this situation. Progress notes are a summary of the progress that the patient has made to help justify the medical necessity of treatment, and a re-evaluation is typically not warranted.
Re-evaluations should be performed in cases where the documentation supports the need for further tests and measurements because there are significant changes in the patient's condition that were not anticipated in the original POT, or the patient is referred for a new condition while still receiving treatment for the original condition. A re-evaluation may also be indicated when the therapist is updating a functional maintenance program. A re-evaluation may also by appropriate when the patient is not making progress as expected, and the therapist feels that the re-evaluation is indicated. Your note should clearly indicate that you have done a re-evaluation, and why the re-evaluation was undertaken.
Re-evaluations should be performed only when the treating therapist feels that it is truly indicated. Therapists should not bill Medicare for a re-evaluation just because it is required by a State Practice Act, Medicaid in your state, or by your facility. Progress notes, just like discharge summaries, are part of the cost of doing business with Medicare. Sorry, the full article is no longer available.