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Eli's Rehab Report

Reader Questions:

New Eval or Re-Eval? Here's How to Decide

Published on Wed Oct 01, 2008

Question: We've treated many patients with a condition that can reoccur or be exacerbated. When that happens, should the therapist perform a new evaluation or a reevaluation?

For example, a patient with a mensical tear or rotator cuff tear was discharged after treatment with a home exercise plan and little to no pain. The patient returns to the clinic a couple of months later with an exacerbation. No changes have taken place, and the therapist, after examining the patient, is using the same ICD-9 code as before. So would this be an eval or a re-eval charge? And what timeframe should we use to determine this?

-- Pennsylvania Subscriber

Answer: You could consider this as a new evaluation, since you had previously discharged the patient from skilled therapy services and she is now returning due to an exacerbation of her condition. Others may state they feel this is a reevaluation, as you are treating the patient for the same diagnosis.

Whichever you choose, the documentation must support the CPT code billed. In addition, you may have to consider the patient's benefit coverage, since some insurance payers may only reimburse for one evaluation per diagnosis per year, one evaluation per year, or one evaluation per every so many months.

-- Reader Questions were answered by Rick Gawenda, PT, director of PM&R at Detroit Receiving Hospital and owner of Gawenda Seminars.

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