This article will help answer the following common questions:
- When should I use an Initial Evaluation vs. Re-Evaluation?
- What is the difference between a Re-evaluation and a Progress Note?
- What is a Certification Period and when is Re-certification necessary?
- What note types can satisfy the needs for Recertification?
1. When should I use an Initial Evaluation vs. Re-Evaluation?
Initial Evaluation: CPT Codes: 97161-97163,97165-97167
An Initial Evaluation is performed by a qualified therapist at the start of a new episode of care to assess the patient’s condition and establish a Plan of Care (POC). According to Medicare Benefit Policy Manual, Chapter 15, Section 220.3, it includes:
- A professional judgment of the patient's condition
- Objective measurements and functional assessments
- Determination of the need for skilled therapy services
- Development of measurable, time-based goals
- Creation of a treatment plan (POC), certified by a physician or NPP
An Initial Eval is required when either:
- The patient is new and hasn’t had therapy before
- The patient had therapy in the past but was discharged, and now needs therapy again—either for the same issue or a new one. The patient may have been discharged before due to any of the following reasons: therapy was no longer helping, they didn’t need therapy for a while, or their medical condition changed in a major way.
- For patients referred to multiple disciplines, an Initial Evaluation is needed for each unique discipline.
Re-evaluation: CPT Codes: 97164, 97168
A Reevaluation is a focused, episodic reassessment of a patient during an ongoing plan of care. Per Medicare Benefit Policy Manual, Chapter 15, Section 220.3(C), it is indicated only when there is a significant clinical need, such as:
- There is a significant, unanticipated change in the patient’s condition or functional status—either improvement or decline—that was not anticipated in the current Plan of Care.
- New clinical findings have emerged that were not present at the start of care.
- The patient is not responding to treatment as expected, indicating a possible need to modify the current Plan of Care.
Reevaluations are not routine or scheduled; they must be medically necessary and supported by documentation.
2. What is the difference between a Re-evaluation and a Progress Note?
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. In this situation, Progress Notes are most appropriate for routine continuous assessment of the patients expected progress.
3. What is a Certification Period and when is Re-certification needed?
A Certification period is the length of time during which a physician or non-physician practitioner (NPP) certifies the need for Medicare-covered therapy services.
The Certification period, as defined by Medicare is valid for the duration of the plan of care established by the therapist and signed and dated by the physician or non-physician practitioner, OR 90 calendar days from the start of care - whichever is less.
Ex. At Initial Evaluation therapist establishes a POC for 2x/week for 8 weeks, and the POC is signed and dated by the physician or NPP. this certification is valid for 8 weeks, since 8 weeks is less than 90 days. Any change to the POC that includes a dated physician signature qualifies as a re-certification.
A few key points regarding certification periods:
- Standard duration: 90 days (3 months) from the start date of the therapy plan of care
- This period begins on the date the initial evaluation or therapy begins, not the date the plan is signed.
- Recertification is required if therapy continues beyond 90 days or beyond the established POC.
- Recertification window: A provider must recertify on or before day 91 of ongoing therapy.
Note: Some states may be more restrictive than the Medicare requirements, so you must always be aware of and follow your states practice act.
4. What note types can satisfy the needs for Recertification?
ANY of the Note types listed below, when signed by the therapist and physician or non-physician practitioner (NPP)will qualify to Re-certify the treatment plan.
- Re-Certification Note Type: No Specific CPT Code associated with this note type. In Stride, this Note Type can be utilized
- Progress Note: No Specific CPT Code Associated with this note type.
- Re-Evaluation: CPT Codes: 97164, 97168 are associated with this note type, and documentation must support use of the CPT Code. See above, Question 1.
- Initial Evaluation: CPT Codes: 97161-97163,97165-97167 are associated with this note type, and documentation must support the use to the CPT Code. See Above, Question 1.
Within the documentation itself, regardless of the above not type utilized, the documentation must include the following to qualify for recertification:
- Diagnoses
- Long term treatment goals
- Type, amount, duration and frequency of therapy services
- Dated signature of therapist establishing updated plan of care
- Dated signature of physician or non-physician practitioner certifying the need for therapy services
Information sourced from:
- https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=53309
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OutptRehabTherapy-Booklet-MLN905365.pdf\
- https://gawendaseminars.com/
Related Articles:
Stride Settings for Certification Periods