SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing

A53309

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General Information

Source Article ID
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Article ID
A53309
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2020
Revision Ending Date
N/A
Retirement Date
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Article Text

Therapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians i.e., a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP).

Therapy evaluation, re-evaluation, and formal testing codes can only be billed when the medical record supports the completion of a medically necessary comprehensive evaluation or formal test. Documentation must support that the service was needed based on the patient’s current clinical status or condition. Medicare does not reimburse for services related solely to workplace skills and activities. Additional evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patient’s therapy progression. Note that routine continuous assessment of the patient's expected progress in accordance with the plan of care is not separately reimbursable as a re-evaluation or formal testing service.

Initial Evaluations - (i.e., CPT ® 97161-97163,97165-97167)
Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline i.e., physical therapist (PT), and/or occupational therapist (OT), and/or SLP, will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for:

• A new patient who has not received prior therapy services.
• A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:

    • Patient no longer significantly benefited from ongoing therapy services or;
    • Patient no longer required therapy services for an extended period of time or;
    • Patient experienced a significant change in medical status that necessitated discharge.
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• A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition. Example: A patient is currently receiving treatment following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.

For additional information, see the attached “Medical Necessity of Therapy Services” article in the Related Coverage Documents link below.

Re-Evaluations- (i.e., CPT®97164, 97168)
Re-evaluations are separately reimbursable when the medical record supports that the patient's clinical status or condition required the additional evaluative service. When medical necessity is supported, a re-evaluation is appropriate and is separately billable for:

• A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
• A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.

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.  Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services an is included in services and procedures.

Formal Testing (i.e., CPT®97750, 95851-95852)
Formal testing services are considered inclusive (not separately reimbursable) when they are provided on the same day as an initial evaluation or re-evaluation service. Formal testing services are separately reimbursable when the medical record supports that the patient's clinical status or condition required the additional testing service. Formal testing services should not be billed using therapy service or procedure codes. When medical necessity is supported a formal test is appropriate and is separately reimbursable when documentation supports the completion of a formal, date signed, distinctly identifiable findings report which includes:

• Testing and/or measurement results with comparative values for specific standardized grading scales.
• Provider’s interpretation of results.
• Support of how the findings were incorporated into the therapy plan of care, when applicable.

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 formal test. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services and is included in services and procedures.

Sources:
Current Procedural Terminology (CPT) Manual
• CMS Internet Only Manual (IOM), Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 220.3.5(A), 230.1.
• IOM, Medicare Benefit Policy Manual,, Publication 100-02, Chapter 16, Section 150

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2020 R4

This article was updated to change the title of the article from Therapy Evaluation and Assessment Services to Therapy Evaluation, Re-Evaluation and Formal Testing, and verbiage was updated.

The following CPT codes were removed from Group 1: 95831, 95832, 95833, 95834

01/01/2017 R3

Article converted to Billing and Coding. No change is coverage was made.

01/01/2017 R2 Corrected links to Benefit Policy Manual and Claims Processing Manual
01/01/2017 R1 This article is revised to change the initial PT/OT evaluation codes to 97162-97163 for PT and 97165-97167 for OT and Reevaluation codes 97164 & 97168 and deleted CPT® codes 97001, 97002, 97003 & 97004 effective 01/01/2017. Also, this article now combines JEA A53308 into the JEB article A53309 so that both JEA and JEB contract numbers will have the same final MCD article number as JEB A53309.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
11/14/2023 01/01/2020 - N/A Currently in Effect View
10/28/2020 01/01/2020 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • PT
  • OT
  • Evaluation
  • Re-evaluation
  • 95851
  • 95852
  • 97161
  • 97162
  • 97163
  • 97164
  • 97165
  • 97166
  • 97167
  • 97168
  • 97750