Therapists often get confused between when they should bill a progress note and when they should bill a re-evaluation. However, there are extremely strict guidelines when it comes to using each code.
Re-evaluations are not routine and shouldn’t be billed as such. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).
According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.”
When medical necessity is supported, a re-evaluation (97164) is appropriate for:
A patient does not respond as anticipated to the treatment outlined in the current plan of care, and a change to the plan is necessary.
A patient undergoes surgery mid-plan of care.
A former patient returns to therapy after discharge with complaints similar to those you treated previously.
A current patient develops a newly diagnosed, related condition.
A current patient develops a newly diagnosed, unrelated condition.
A patient undergoing therapy treatment demonstrates an unexpected and significant change in status.
It is important to note that 97164 can be billed and bundled with other 97xxx codes with the addition of the 59 modifier to indicate the service is separate and distinct.
Still confused or have additional questions about the use of 97164? Contact LRS at hello@lincolnrs.com and we can help!