Evaluation
True or False: We cannot utilize Z codes as a diagnosis code in physical therapy
False- Z codes can be utilized as secondary codes, not as primary
This is where your re-eval dot phrase should be in your documentation
within the assessment paragraph
When should occurrence codes be filled out?
Impairment start date on day of evaluation - always by primary PT
Treatment start date on first day a charge is dropped other than evaluation. May be on evaluation day, or first follow up.
Give 3 examples of a precaution that should be documented and carried through each visit
Unstable HTN- check vitals before exercise; Weight bearing status; lifting restrictions; surgical protocols; osteoporosis- no joint mobilizations; history of/active cancer- no e-stim (if applicable)
T or F: Hypertension is a precaution
If unstable HTN, yes. If controlled HTN, no.
List the necessary components that should be including in your initial evaluation assessment paragraph.
Rehab diagnosis, summary of objective findings, functional limitations, and what will be included in PT POC.
Don't need to re-state subjective reports or PT frequency since it's elsewhere in the evaluation.
When is it appropriate to drop a re-eval charge?
If the plan of care is changing i.e. change of status, new ICD-10 code
I'm evaluating a patient today with Medicare insurance. How long should I set my POC for?
90 days - to avoid needing to submit a re-cert, make all POC for Medicare patients 90 days. Use "t+90" to populate the end plan of care date
"Patient tolerated treatment session. Continue per POC." Is this an appropriate daily note assessment?
No, there should be more documentation regarding the patient's tolerance and a general guidance/intention for next session.
When completing occurrence codes, what should the impairment start date be?
If chronic issue, use date of PT referral. If surgical or acute injury, use date of injury/surgery
True or False: My rehab diagnosis should be the same as the reason for referral
False - the rehab diagnosis does not have to match the referral diagnosis.
Who is responsible for ensuring a patient has a re-eval every 30 days?
Everyone! PT, PTA, and front desk are all expected to uphold re-eval timelines when necessary.
True or False: My patient still needs a Medicare cert and dot phrase when Medicare is their secondary insurance.
True
STS (sit to stand), LTR (lower trunk rotation), and NT (not today) are approved abbreviations that I can use
False- and NT = not tested.
Name the components that should be included in your discharge visit.
updated objective measures, discharge summary, completed letter to referring provider
I'm evaluating a patient for neck pain who recently got discharged for their pelvic floor. I notice my evaluation visit is linked to their old pelvic floor referral. What should I do?
Let Steph and Renea know
Sneha is treating a patient of Shirah's who arrived late for their appointment. The patient is due for a re-eval in 5 days, and they don't have any other appointments booked. What should Sneha do?
Sneha should perform the re-eval and have the patient schedule more follow ups with Shirah and Rodniel if appropriate.
I'm discharging my Medicare patient today, 3/18/25. The original medicare cert expired yesterday. What should I do?
Submit a new medicare cert with dot phrase. treatment start date and end date 3/18/25.
List the parameters that should be included when documenting manual interventions
Justification, Modality (soft tissue, joint mobilization, etc); Duration performed; location of intervention
Today with your initial evaluation you spent 30 minutes on subjective history and objective exam, 5 minutes educating your patient on the findings and POC, and 5 minutes instructing them on their initial HEP. What are your charges?
30 minutes evaluation (1 unit)
10 minutes self care (1 unit)
Patient is being evaluated for low back pain radiating into LLE. PMH: Guillan-Barre syndrome, PTSD, plantar fasciitis in her L foot. Pt has difficulty sleeping, walking, lifting, and unable to work due to pain. What complexity evaluation should I bill for?
Moderate - 1-2 personal factors impacting plan of care, and presenting with 3 or more impairments, functional limitations, and/or participation restrictions.
Need to use dot phrase if billing mod or high complexity
You spent 8 minutes performing a re-eval today, 10 minutes on manual therapy, and 12 minutes on therapeutic exercise. What are your charges?
20 minutes of therex, 10 minutes of manual
I'm re-evaling my Medicare patient today. Their initial medicare cert expires tomorrow, but they still need two more weeks of PT. How long should my new Medicare cert be set for?
At least 30 days. You want to account for potential cancellations or no shows that may extend the timeline of their POC.
Do you bill for heat/ice? Is this considered skilled time?
Yes - heat/ice should always be billed under modalities and included under skilled time
I'm a PTA treating a Medicare patient for their first follow up. I notice the occurrence codes are not filled out but self care was billed at the evaluation. What should I do?
Complete the occurrence codes including the impairment start date (referral date) and treatment start date (date of initial eval)