Eli's Rehab Report

Question: When our physical therapist performs a re-evaluation on the same day as other modalities, such as therapeutic exercises, the re-evaluation is always denied. How should we code this?

Pennsylvania Subscriber

Answer: Unfortunately, 97002 (Physical therapy re-evaluation) is listed as a component of PM&R codes 97012-97530 and 97535-97545 under the Correct Coding Initiative (CCI) because most insurers feel that re-evaluations are always part of physical therapy modalities and are therefore included in the PM&R therapy codes. On the other hand, if you feel you can prove medical necessity for both the re-evaluation and the modality, modifier -59 (Distinct procedural service) can be appended to 97002.

For example, the patient is receiving physical therapy while recovering from a stroke (436). The patient presents for her normal therapy session but tells the therapist that she fell down the stairs the previous day and is having difficulty moving her left foot. The therapist would perform a comprehensive re-evaluation of the patient to assess whether her needs have changed based on her new injury. If the therapist then performs therapeutic exercises with the patient, he or she could code the claim using 97110 for the therapeutic exercises and 97002-59 for the re-evaluation.

Because this claim likely will raise questions with your carrier (based on the CCI edits), you should send your documentation with the claim to show the insurer why the re-evaluation was medically necessary. This way you will not waste time dealing with requests for additional information.

However, you cannot add 97002 and modifier -59 to all of your therapy claims and expect reimbursement. Some PM&R practices may argue that "the therapist is always reevaluating the patient, so it's OK to bill the code." This is not correct coding and would be considered by your insurer to be an abuse of the code.

Advice for You Be the Coder and Reader Questions was provided by Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.; and Shirley Longfellow, reimbursement specialist at Computerized Thermal Imaging in Lake Oswego, Ore.