Eli's Rehab Report

Question: We have never used the physical therapy re-evaluation code. What does it entail? Also, does the physician have to see the patient during a re-evaluation, or can he sign off on the therapists evaluation?

Iowa Subscriber

Answer: During the patients treatment, you are always assessing and documenting a patients progress, but you are not always evaluating them as you would during a true therapy re-evaluation (97002 for physical therapists, 97004 for occupational therapy re-evaluation). This requires diagnostic and prognostic tests, such as examinations of the patients range of motion, gait, joint integrity, muscle performance, motor skills, ability to perform daily living activities, etc.

The re-evaluation is more formal than the weekly assessments you perform, mainly because Medicare requires that the patients plan of care be reviewed by the therapist and the physician at least every 30 days. To review the plan of care requires a re-evaluation to determine the patients progress. Therefore, it is not sufficient for the doctor to sign off.

The physicians initialing of the plan of care is essentially a prescription noting that the patient still requires therapy. In Medicares eyes, if the physician walked in, signed the therapy re-evaluation, and left, that would equate to dispensing a prescription for a patient whose condition is unfamiliar.