The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency, and duration. There must be an expectation that the condition will improve significantly in a reasonable (and generally predictable) period of time, based on the physician’s assessment of the patient’s rehabilitation potential.

The therapist must document the patient’s functional limitations and therapeutic short- and long-term goals in objective and measurable terms.

Physical therapy is not covered:

• When the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist;

• When the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate;

• When the documentation indicates that a patient has attained the therapy goals or has reached the point at which no further significant practical improvement can be expected. The skills of the physical therapist are not required to maintain function. No more than two to four visits are considered medically necessary to establish a maintenance program;

• When a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of a physical therapist. Normally, visit frequency decreases as the patient’s condition improves; and

• When physical therapy services are duplicative of other concurrent rehabilitation services.

PT EVALUATIONS

Physical therapy evaluations (CPT Code 97001) are required prior to beginning therapy to determine the medical necessity of initiating rehabilitative services.

Patients must exhibit a significant change from normal functional ability to warrant an evaluation. Factors that influence the complexity of the evaluation process include: clinical findings, extent of loss of function, social consider-ations, and the patient’s overall function and health status.

The evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. If the patient presents with multi-system involvement and/or multiple site involvement, all areas/conditions should be assessed at the initial evaluation (such as cervical pain and knee pain; low back pain and rotator cuff; cervical pain and low back pain).

Only one evaluation code should be used for each area assessed.

Therapists consider:

Insurance companies may cover initial evaluations even when it is determined that a skilled level of service is not required as long as the patient’s condition showed a need for the evaluation, even if the goals established by the plan of care are not realized.

The patient will not be eligible for further treatment if the evaluation shows that he or she has reached the maximum therapeutic potential and further therapy would not result in any significant improvement, which happens in many chronic conditions.

Insurance plans may also cover initial evaluations from other therapy disciplines performed on the same beneficiary, provided the referral, evaluation, and plan of treatment are not duplicative.

Documentation requirements: The written evaluation must demonstrate the patient’s need for skilled therapy based on functional diagnosis, prognosis, and positive prognostic indicators. The therapist must have an expectation that the patient will achieve the established goals.

Initial evaluations must contain the following information:

Baseline evaluation data must be objective and measurable and include all applicable areas, such as: cognition, vision/hearing, vascular signs, sensation/proprioception, edema, posture, active range of motion/passive range of motion, strength, pain, coordination, bed mobility, balance (sit and stand), transfers, ambulation (level and elevated surfaces), orthotic/ prosthetic devices, wheelchair use, durable medical equipment (using or required), activity tolerance, wound description (including incision status), special tests (include the name and scores), architectural/safety considerations, and requirements to return to home, school, and/or job. (This is not an inclusive list.)

The treatment plan is meant to serve as a guide to patient care and may be revised as the clinician responds to changes in the patient’s status. The plan of care should include:

PT RE-EVALUATIONS

Re-evaluations (CPT Code 97002) are covered and may be billed as a separate charge only if the documentation shows significant change in the patient’s condition that supports the need to perform a formal re-evaluation.

Reassessments are considered a routine aspect of intervention and are not billed separately from the charge associated with the intervention. Continuous evaluation of the patient’s progress is a component of the ongoing physical therapy services.

Re-evaluations are not routinely covered for purposes of updating the plan of care.

Documentation requirements: The components of the re-evaluation and the documentation requirements are the same as the initial evaluation, but are focused on assessing significant changes from the initial evaluation or progress toward treatment goals.

Marty Kotlar, DC, CHCC, is the president of Target Coding (www.TargetCoding.com). Target Coding, in conjunction with Foot Levelers, Inc., is offering continuing-education seminars on CPT coding and documentation. He can be reached at 800-270-7044, through his Web site, or by e-mail at drkotlar@targetcoding.com