PT and OT Reevaluation Coding

January 4th, 2018 - Find-A-Code
Categories:   CPT® Coding   Physical Medicine|Physical Therapy   Billing   Documentation Guidelines  
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According to CGS Administrators, the reevaluation 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. Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.

Reevaluations are distinct from therapy assessments. Assessments are considered a routine aspect of intervention and are not billed separately from the intervention. For example, a patient is being seen in physical or occupational therapy for shoulder pain and limited shoulder functional range of motion due to capsular tightness. Prior to performing shoulder joint mobilizations, the therapist assesses the patient’s ROM and pain level/pattern to determine the effect of prior treatment and, if further mobilization is warranted, to determine the appropriate mobilizations. After the mobilizations are completed, the ROM is assessed again to determine the effects of the treatment just performed. The time required to assess the patient before and after the intervention is added to the minutes of the treatment intervention (code 97140 in this example). Continuous assessment of the patient’s progress is a component of the ongoing therapy services, and is not payable as a reevaluation.

Consider the following points when billing for a reevaluation.

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