Page 199 - Medicare Benefit Policy Manual

o Other measurable progress towards identified goals for functioning in
the home environment at the conclusion of this therapy episode of
care.

• Clinician’s clinical judgments or subjective impressions that describe the current
functional status of the condition being evaluated, when they provide further information
to supplement measurement tools; and

• A determination that treatment is not needed, or, if treatment is needed a
prognosis for return to premorbid condition or maximum expected condition with
expected time frame and a plan of care.

NOTE: When the Evaluation Serves as the Plan of Care. 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.

The time spent in evaluation shall not also be billed as treatment time. Evaluation
minutes are untimed and are part of the total treatment minutes, but minutes of evaluation
shall not be included in the minutes for timed codes reported in the treatment notes.

Re-evaluations shall be included in the documentation sent to contractors when a re-
evaluation has been performed. See the definition in section 220. Re-evaluations are
usually focused on the current treatment and might not be as extensive as initial
evaluations. Continuous assessment of the patient's progress is a component of ongoing
therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine,
recurring service but is focused on evaluation of progress toward current goals, making a
professional judgment about continued care, modifying goals and/or treatment or
terminating services. A formal re-evaluation is covered only if the documentation
supports the need for further tests and measurements after the initial evaluation.
Indications for a re-evaluation include new clinical findings, a significant change in the
patient's condition, or failure to respond to the therapeutic interventions outlined in the
plan of care.

A re-evaluation may be appropriate prior to planned discharge for the purposes of
determining whether goals have been met, or for the use of the physician or the treatment
setting at which treatment will be continued.