Page 167 - Medicare Benefit Policy Manual

certification/re-certification purposes. Also, if the physician faxes the referral,
certification, or re-certification and forgets to date it, the date that prints out on the fax is
valid. If services provided on one date are documented on another date, both dates
should be documented.

The EPISODE of Outpatient Therapy – For the purposes of therapy policy, an outpatient
therapy episode is defined as the period of time, in calendar days, from the first day the
patient is under the care of the clinician (e.g., for evaluation or treatment) for the current
condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last
date of service for that discipline in that setting.

During the episode, the beneficiary may be treated for more than one condition; including
conditions with an onset after the episode has begun. For example, a beneficiary
receiving PT for a hip fracture who, after the initial treatment session, develops low back
pain would also be treated under a PT plan of care for rehabilitation of low back pain.
That plan may be modified from the initial plan, or it may be a separate plan specific to
the low back pain, but treatment for both conditions concurrently would be considered
the same episode of PT treatment. If that same patient developed a swallowing problem
during intubation for the hip surgery, the first day of treatment by the SLP would be a
new episode of SLP care.

EVALUATION is a separately payable comprehensive service provided by a clinician, as
defined above, that requires professional skills to make clinical judgments about
conditions for which services are indicated based on objective measurements and
subjective evaluations of patient performance and functional abilities. Evaluation is
warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These
evaluative judgments are essential to development of the plan of care, including goals and
the selection of interventions.

FUNCTIONAL REPORTING, which is required on claims for all outpatient therapy
services pursuant to 42CFR410.59, 410.60, and 410.62, uses nonpayable G-codes and
related modifiers to convey information about the patient’s functional status at specified
points during therapy. (See Pub 100-04, chapter 5, section 10.6) NOTE: Functional
reporting requirements are no longer applicable for claims for dates of service on and
after January 1, 2019. See the NOTE at the beginning of Section 220.4 for more
information about the discontinuation of functional reporting requirements.

RE-EVALUATION provides additional objective information not included in other
documentation. Re-evaluation is separately payable and is periodically indicated during
an episode of care when the professional assessment of a clinician indicates a significant
improvement, or decline, or change in the patient's condition or functional status that was
not anticipated in the plan of care. Although some state regulations and state practice
acts require re-evaluation at specific times, for Medicare payment, reevaluations must
also meet Medicare coverage guidelines. The decision to provide a reevaluation shall be
made by a clinician.