Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG111)

Initial PT/OT/AT/SLP and E/M evaluations are covered for a patient’s first encounter for a new injury/condition (or same/similar complaint after discharge) while re-evaluations are covered only when not routine and documentation shows a significant change/exacerbation requiring clinical judgment; screenings, routine/recurring progress checks, expected post-hospital deconditioning evaluations, certain SLP screenings/re-evals (e.g., Medicare Part B unpriced S9152) and improperly billed duplicate or bundled services are excluded. Key requirements: documentation must demonstrate medical necessity with objective findings/standardized assessments, goals and prognosis, clinician judgment, therapist-performed initial evals, CPT-based complexity selection, one initial-evaluation code per encounter, untimed re-evals billed once, and adherence to same-day bundling and single-unit billing rules.

"Initial evaluation for a new condition by a Physical Therapist, Occupational Therapist, or Athletic Trainer is defined as the evaluation of a patient: For which this is their first encounter with t..."