Wiki Therapy evaluation or re-eval?

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CXZook

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Our PT/OT will be evaluating NICU babies at each milestone, 2-3 months - 8-9 months - 15 -20 months - and 20 months until the age of 2. Thay are being seen as outpatients and they will not see the patient in between these visits for treatment. We know the first visit will be an evaluation CPT code, but would the remaining visits be a re-evaluation or an evaluation each time? As of now the diagnosis will not change, it will stay the same as what was on the referral.
 
If the patient was discharged, and there was no treatment or plan of care in between, my thought would be it is a new eval every time. I have not dealt with pediatric therapy though so not an expert in this. The description of 97164 is Re-Evaluation of physical therapy established plan of care. If there is no plan of care currently established, how can it be re-evaluated? However, I also have a feeling there could be other components to this like, should the evaluation codes be used for this type of process? Is there some other way this is supposed to be billed? It makes me think of CPT code area 96110, 96111 but these are more for the PEDS, ASQ, mental health and pediatricians usually do those. That code range may not apply for therapy.
I think it would probably be a new eval every time if there was no treatment or plan of care in between. The diagnosis shouldn't matter.
You would also have to take into account if the patient is getting any other treatment such as home therapy or other services concurrently.

If you look at the CMS Local Coverage Article:
CPT 97161-97163 – Physical therapy evaluation CPT 97165-97167 – Occupational therapy evaluation
When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The goal, frequency, and duration of treatment are implied in the diagnosis and one-time service. The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.
CPT 97164 – Physical therapy reevaluation CPT 97168 – Occupational therapy reevaluation
The reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services.
Continuous assessment of the patient’s progress is a component of the ongoing therapy services, and is not payable as a reevaluation.
  • Do not bill therapy screenings utilizing the evaluation codes. Screenings are not billable services.
 
@amyjph thank you so much for sharing your expertise. I too believe that an evaluation is the appropriate charge each time the patient returns, but wanted to see what other APPC thoughts were on this. Thank you for the CMS article, if the evaluation serves as the plan of care, our plan of care is only good for 90 days max. These patients are not coming back until 6 months therefore POC has expired. New order and new eval will be needed at the next 6 month visit. Thanks again I appreciate all the information!
 
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