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Raising the Bar in Rehab

What Is An Evaluation Worth To You?

Published June 10, 2010 1:33 PM by

We had a discussion at the end of the day regarding our billing with some staff who had floated over from another location. The conversation was this: For a 45-minute evaluation with a patient, how do you bill for your time? Assume 15 minutes is spent with the formal evaluation - testing and observation - and 30 minutes ambulating, providing exercises and reviewing goals.

Side One: 45 minutes is equivalent to three units, so you should bill one evaluation (two units) and one unit of gait training.

Side Two: Since you spent 30 minutes performing gait training and ther-ex, you should bill one unit each for a total of one evaluation, one gait training and one ther-ex; this would total four units.

In either case, 45 minutes is being used, but one is more productive compared to the other. So, I'm looking for some comments here - what do you normally do? Does your employer have a policy for this? If so, what is expected for your billing with evaluations?

(Another part of this debate included questioning if an evaluation must be billed first, before gait training or ther-ex are billed. If you provide 10 minutes of crutch training to a patient, is that really a PT evaluation or is it more appropriate for one unit of gait training? But, that's another topic for a later date.)



Thanks for the feedback.  I agree with you.  I think sometimes the time spent evaluating a patient is also dependent on how involved their case is.  Some patients with multiple comorbidities consume a lot of time to evaluate, whereas a patient with a great health history and one diagnosis (torn ACL) may be more straight-forward.

Again, good to hear from you!  

Lisa June 12, 2010 9:00 AM

An evaluation is an untimes procedure code, 97001.  Regardless of whether it was 15 minutes or an hour, it is still billed as 1 code of 97001.  Your organization may track for productivity measures 15 minute units (called RVUs), however, the bill should only have one CPT billed for the evaluation regardless of time spent.

Most payers (including MCR) allow for billing treatment the same day of evaluation.  If in fact the evaluation was only 15 minutes and the additional 30 minutes were spent gait training and therex (not assessing as part of the evaluation), that time is uniquely billable.  That said, I find it hard to believe that a thorough evaluation, including history, strength, ROM, and gait assessment was completed in 15 minutes.  If the gait training was inclusive of gait assessment, it should be rolled into the evaluation.

The 30 minutes could be one unit of gait - 97116 and one unit therex - 97110, if truly independent of the evaluation.

It is not possible to bill for 4 15 minute units (RVUs) in a 45 minute treatment.  In one word, this is fraudulent.

Jim, Physical Therapy - Director of Ambulatory Services and Billing Compli, The Rehabilitation Hospital of the Cape and Island June 11, 2010 10:51 AM
East Sandwich MA

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