What’s the Difference Between Re-Evaluations and Progress Reports?

Note: This article contains information that is only relevant to American clinics.


I was reading a recent article by Rick Gawenda the other day and it talked about how many therapists are under the impression that they need to bill insurance carriers for re-evaluations every 30 days. They seem to think that Medicare, or their state practice act, needs them to re-evaluate patients on a fixed schedule. Well, the fact is, a lot of these therapists might be confusing ‘re-evaluations’ with ‘progress reports’ which more often than not, are what Medicare or their employer is actually referring to.


Not to belabour the point, but in past articles we’ve mentioned that there are only certain situations in which one should be billing Medicare or other insurance carriers for re-evaluations–a fixed time interval certainly isn’t one of those reasons. To reiterate, a re-evaluation isn’t warranted unless: there’s been a significant improvement or decline in a patient’s condition, there have been new clinical findings, or the patient hasn’t responded to the treatment outlined in the current plan of care.


Rick’s article stated that “an example of a significant change in the patient’s condition could be that a patient had a total knee replacement, began outpatient therapy, and then went in for a manipulation.” In such a case, a re-evaluation may be warranted if there are changes in a patient’s range of motion, pain levels, strength, etc.


In terms of progress reports, Medicare Part B therapy services require therapists to complete a progress report at least once every ten visits. This progress report becomes a part of the patient’s medical record. While therapists are required to fill out one of these reports, they are not the same thing as a re-evaluation, so you shouldn’t be surprised when those those re-evaluation remittances that you were expecting to collect are declined.


If you ever find yourself in doubt about whether you should be billing for a re-evaluation instead of a progress report, refer back to your state’s practice act. Double-check whether or not you’re required to perform the former or the latter—you may be able to figure out why those claims are being denied.


For more articles like this, visit the Gawenda Seminars and Consulting website.

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