Eli's Rehab Report

Published on Thu Dec 26, 2013 PDF

Question: I’m wondering when therapy re-evaluations are considered reasonable and necessary. Would you shed some light on this?

Answer: You’re allowed to report a therapy re-evaluation (97002, Physical therapy re-evaluation and 97004, Occupational therapy re-evaluation) only if your documentation shows a significant change in the patient’s diagnosis or condition. The therapist may need to modify anticipated goals and expected outcomes following the re-evaluation of patient progress.

You can also report 97002 or 97004 if the therapy re-evaluation is part of the plan of treatment with clinical rationale or is supported by a supplemental physician order.

Remember: Your therapy re-evaluations must contain all the components of an initial evaluation, and you should only report one unit on a single day of service.