Over the years, we’ve received a lot of questions on the WebPT Blog—and one of the most frequently asked ones has to do with the difference between patient progress notes and re-evaluations, specifically in relation to billing. To be perfectly clear, Medicare will not pay for a progress note. According to compliance expert Tom Ambury, “It is not appropriate to bill...when reporting ‘normal predictable progress’”—regardless of the timing or whether “a more thorough assessment is being performed.” That’s because Medicare “considers this to simply be a good documentation practice, and therefore it would not be payable under Medicare guidelines.”

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The Unbillable Progress Note

As Ambury writes in this article, “according to Medicare, the progress note provides the continued justification of the medical necessity of the treatment.” As of January 1, 2013, therapists are required to complete a progress note for every Medicare patient on or before every tenth visit throughout that patient’s course of care. As a reminder, the licensed therapist must be the one to complete the progress note (an assistant cannot complete this task, although he or she can participate in the process), and Medicare does not require a physician or nonphysician provider (NPP) to sign the note. Ambury also explains that the dates for plan of care (POC) recertification “do not affect the date of the required progress report.” As such, “there could be several progress reports before the recertification,” he says.

Ambury suggests following these three tips to ensure you’re completing your progress notes correctly and on time:

  1. “After the initial evaluation, establish a schedule to perform a progress report on or before the [patient’s] tenth visit.”
  2. Allow an assistant to participate in the progress report process, “performing those aspects of the progress report that fall within [his or her] scope of practice,” but ensure you as the licensed therapist are the one responsible for “clinical judgment, decision making, and [signing the note].”
  3. Demonstrate that you provided treatment to the patient within the reporting period by signing the treatment note.

For a progress note example, check out Ambury’s full article here.

The Progress Note/Re-evaluation Conundrum

Now, Medicare will pay for a re-evaluation, but a re-eval and a progress note are two very different things—and it is not appropriate to bill for a re-eval when you complete a routine progress note. In fact, therapists should only bill for re-evaluations under a very select set of circumstances. According to WebPT President and Co-Founder Heidi Jannenga, re-evaluations are only appropriate if the patient presents with a new diagnosis or at least one of the following situations applies:

  • “Through your own clinical assessment, you note a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the POC for that interval.
  • “You uncover new clinical findings during the course of treatment that are somewhat related to the original treating condition.
  • “The patient fails to respond to the treatment outlined in the current POC, and you determine that a change to the POC is necessary.
  • “You treat a patient with a chronic condition and you don’t see him or her for treatment very often.
  • “Your state practice act requires re-evaluations at specific time intervals.”

The Billable Re-Evaluation

To add to the confusion, some providers believe that:

  1. Medicare doesn’t reimburse for re-evaluations at all and/or
  2. Billing for re-evals increases the risk of an audit.

Luckily, neither is true. As Jannenga explained in this blog post and during WebPT’s latest webinar, “the first rumor came about because therapists received claim denials when they billed for a re-evaluation—but it was only because they failed to attach modifier 59 to the claim when they performed the re-eval on the same day they provided other services.” In accordance with the Correct Coding Initiative (CCI), you must use modifier 59 to notify Medicare that you performed a re-evaluation as a wholly separate and distinct service; otherwise, you won’t get paid for it. As for rumor number two, Jannenga says, “If you complete a re-evaluation in accordance with the criteria noted above—and you correctly document and bill for it—then you won’t raise any red-flags.” That being said, if you’re using re-eval codes excessively, then Medicare may very well “take action in the form of audits and payment recoupment if they determine that the re-evaluations you billed were not necessary or applicable.” In other words, billing for a reevaluation in and of itself won’t trigger an audit; but, demonstrating “questionable billing practices” might.

During the webinar, Ambury brought up another great point: “Defensible documentation is key here,” he said. So, before you bill, make sure your documentation “tells your patient’s story” and “justif[ies] your clinical decision—including the decision to perform a re-evaluation.” In other words, your billing must line up with your documentation, which must line up with your treatment intervention, regardless of the service you’re providing. As for non-Medicare insurance companies, while most payers reimburse for re-evaluations, it’s always a good idea to contact each one directly prior to billing for this service.

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