In physical therapy, it is crucial to understand the distinctions between progress notes and re-evaluations. These terms, frequently confused and used interchangeably, are crucial in documenting a patient's recovery journey. However, they each have distinct features and applications.
What is a Progress Note?
A progress note is a document that records the patient's treatment journey, highlighting their response to therapy, changes in their condition, and plans for future interventions. It is the cornerstone of clinical documentation, providing a detailed and chronological record of the patient's treatment.
The Role of a Progress Note in Physical Therapy
In physical therapy, a progress note serves as a roadmap to a patient's recovery. It provides detailed insights into the patient's response to the therapy, indicating whether the treatment plan is effective or needs adjustment. Moreover, it enables a seamless transition of care when a patient's treatment is handled by multiple therapists.
Key Components of a Progress Note
A progress note typically includes:
Patient's History: A comprehensive record of the patient's medical history and current health status.
Treatment Goals: Clear and measurable objectives for the patient's recovery.
Intervention Details: Detailed account of the therapy provided, including the type of exercises, their frequency, intensity, and duration.
Patient's Response: How the patient responds to the treatment, including any changes in symptoms or functional abilities.
Plan of Care Revisions: Any modifications to the initial plan of care, based on the patient's response to the treatment.
Can I Bill for a Progress Note?
Contrary to common misconceptions, a progress note is not a billable service. This is a fundamental aspect of good clinical documentation and is considered part of the standard care process.
Medicare considers the progress report to simply be a "good documentation practice, and therefore it would not be payable" under Medicare guidelines.Therefore, while it is crucial for tracking a patient's progress, it does not warrant a separate billing procedure.
What is a Re-Evaluation?
A re-evaluation is a thorough reassessment of a patient's condition, performed when there is a significant and unexpected change in the patient's condition. It is signified by the CPT code 97164 in physical therapy billing.
The Role of a Re-Evaluation in Physical Therapy
A re-evaluation is an essential tool for physical therapists when there is a need to assess the patient's condition beyond the regular treatment review. It serves as a critical checkpoint when the patient’s condition has significantly improved, declined, or changed in an unexpected manner, warranting a formal evaluation to revise the treatment plan.
When Should I Perform a Re-Evaluation?
Some of the indicators for a re-evaluation include:
New Clinical Findings: Discovery of new symptoms or clinical findings that are not part of the original treatment plan.
Significant Change in Patient's Condition: A notable improvement, decline, or unexpected change in the patient's condition.
Non-Responsiveness to Treatment: The patient does not respond to the treatment as expected, indicating a need for a revised plan of care.
When Should I Bill 97164 (PT Re-Eval)?
Billing for a re-evaluation (CPT code 97164) should only be considered under specific circumstances. It is not a routine procedure and is only warranted if the patient's condition meets one of the three criteria above. Notable changes, improvement, declines or non-responsiveness could necessitates a formal re-evaluation.
Remember, a re-evaluation should not be performed or billed just because it is the 10th visit or because a certain amount of time has elapsed. Instead, it should be driven by the need to re-establish appropriate treatment goals and interventions due to a significant change in the patient's condition.
In conclusion, while both progress notes and re-evaluations are integral to physical therapy, they serve different purposes and should not be confused. A progress note is a standard part of clinical documentation and is not a billable service. In contrast, a re-evaluation is a billable service under specific circumstances, represented by the CPT code 97164. Understanding these distinctions is essential for providing effective patient care and ensuring accurate billing practices.