How do we bill an evaluation code at the time a rehab procedure is performed?
The codes for an evaluation and rehab procedure would be shown on the claim. 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. (Reference: CMS Pub 100-02, Ch 15, 220.3 C). The need for documentation to support rehab procedures separate from initial evaluation should be included.
Although some regulations and state practice acts require re-evaluation at specific intervals, for Medicare payment, re-evaluations must meet Medicare coverage guidelines. The decision to provide a re-evaluation shall be made by a clinician. Reference: Centers for Medicare and Medicaid Services (CMS) Publication 100-02, Chapter 15, Section 220 C Re-evaluations are not required; they are to be implemented when there is an indication for one. Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, failure to respond to the therapeutic interventions outlined in the plan of care, or upon discharge.
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- How do we bill an evaluation code at the time a rehab procedure is performed?
