When is the Right Time to Bill for a Re-evaluation?

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


If you ever find yourself wondering about the right time to bill an insurance provider for a re-evaluation, rest assured that you aren’t the only one. You might be inclined to think that you should bill them after you’ve re-certified a Medicare patient, or on the same day that you reported on functional limitations and G-codes–but, doing so can cause your claim being denied.


A recent article from our friend Rick Gawenda of Gawenda Seminars & Consulting informed us that “the simple answer is no, a re-evaluation is not appropriate to bill for the sole purpose of writing a progress report, doing a Medicare re-certification, and/or reporting functional limitation G-codes.”


Rick then went on to tell us about the most appropriate times to bill an insurance carrier, including the Medicare program, for a re-evaluation. They are as follows:


  • The therapist’s assessment points to a significant improvement, decline, or variation in the patient’s condition or functional status that was not anticipated in the plan of care for that interval
  • New clinical findings
  • The patient has failed to respond to the treatment outlined in the current plan of care


So, if you’re ever in doubt about whether or not you should be billing your patients’ insurance providers for a re-evaluation, or if you’ve had these types of claims denied in the past, do your best to remember the above criteria.


And at the end of the article, Rick raised a question; how do you account for time spent gathering subjective and objective data to writing a progress report, or completing a Medicare recertification? The answer to that question and more can be found on the Gawenda Seminars & Consulting website.

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