97002 (Physical therapy re-evaluation) is listed as a component of PM&R codes 97012-97530 and 97535-97545 under the Correct Coding Initiative (CCI) because most insurers feel that re-evaluations are always part of physical therapy modalities and are therefore included in the PM&R therapy codes. On the other hand, if you feel you can prove medical necessity for both the re-evaluation and the modality, modifier -59 (Distinct procedural service) can be appended to 97002.
For example, the patient is receiving physical therapy while recovering from a stroke (436). The patient presents for her normal therapy session but tells the therapist that she fell down the stairs the previous day and is having difficulty moving her left foot. The therapist would perform a comprehensive re-evaluation of the patient to assess whether her needs have changed based on her new injury. If the therapist then performs therapeutic exercises with the patient, he or she could code the claim using 97110 for the therapeutic exercises and 97002-59 for the re-evaluation.
Because this claim likely will raise questions with your carrier (based on the CCI edits), you should send your documentation with the claim to show the insurer why the re-evaluation was medically necessary. This way you will not waste time dealing with requests for additional information.
However, you cannot add 97002 and modifier -59 to all of your therapy claims and expect reimbursement. Some PM&R practices may argue that “the therapist is always reevaluating the patient, so it’s OK to bill the code.” This is not correct coding and would be considered by your insurer to be an abuse of the code.
Physical Performance Tests:These tests are often performed to monitor the effectiveness of a patients rehabilitation program. For example, a truck driver injures his back and undergoes physical and occupational therapy before returning to work. The physiatrist and therapist believe that the patient is well enough to go back to his job, so the therapist asks the patient to bend to the floor, pick up 50 pounds, and lift it onto a shelf at shoulder level. The patient successfully repeats the procedure four more times, and then the therapist writes his or her assessment of the patients condition. The documentation should include the date, the patients name, and the assessment. For example, Based on testing, this patient can return to work, although he is advised to lift no more than 50 pounds a maximum of 25 percent of the day; 35 pounds for half of the day, and 20 pounds for the remaining 25 percent of each workday.
Patient should report back with any problems immediately. Patients muscle strength and functional capacity is rated at 75 percent of his normal capacity, and he is advised to continue his range-of-motion and strength-training exercises at home on his own. In addition, the patients file must include a copy of the current treatment plan, which must be signed by the patients physician every 90 days.
Any additional tests that are performed, such as the patient performing floor-to-waist lifts or stair climbing, require separate documentation explaining the reason for the test and the assessment. Because this is a timed code, there is no need to report the number of areas tested, and the time should be added together and reported as separate units of the code. For instance, if the therapist spent 30 minutes with the patient, two units of 97750 would be reported.