Eli's Rehab Report

You Be the Coder:

Therapy Re-Evaluation and Modality on the Same Day

Published on Thu Nov 01, 2001

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Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: Our insurer requires differing diagnoses when we bill for a physical therapy re-evaluation (97002) and a modality on the same day, but I cannot find any requirements stating that this should be the case. Should we use a modifier to cut down on these denials? We are billing for the PT's re-evaluations as incident to using the doctor's ID number.

Georgia Subscriber

Answer: It's possible that your insurer has a policy against a physician billing a physical therapy re-evaluation code. Normally 97002 can be billed with therapy (such as therapeutic exercises, 97110, or gait training, 97116), but some states have laws against physicians billing for PT evaluations or re-evaluations. This is based on state-licensing laws and varies depending on where you practice.

Although the remainder of PM&R codes can normally be billed by the physiatrist, the PT and OT evaluation and re-evaluation codes are often reserved strictly for PTs and OTs. The codes are 97001 (PT evaluation), 97002 (PT re-evaluation), 97003 (OT evaluation) and 97004 (OT re-evaluation).

This means that your PT re-evaluations, billed incident to under the doctor's PIN, may be rejected due to state law. To confirm this as the reason for your recent denials, you should request from your carrier, in writing, the specific reasons why the code was rejected, noting that a CCI edit does not prohibit billing the codes together, so a modifier or alternate ICD-9 Code should not be needed. They should respond with the exact reasons.

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