Cigna therapy evaluation coverage update

Coverage Criteria for Evaluations and Re-evaluations

inv-01: Initial Evaluation

Initial evaluations are covered when ALL of the following are met

Initial evaluation eligibility: Patient has first encounter with the practitioner or practitioner group for a new injury/condition or the same/similar complaint after discharge; the initial evaluation documents necessity of a course of therapy through objective findings and subjective patient/caregiver report; the evaluation is completed by the therapist or physician/Non-Physician Practitioner who will provide the therapy services; and all pertinent areas/conditions are assessed when multi-site or multi-system involvement is present.

References PT/OT/AT evaluation definitions and requirements.

inv-02: Code Level Determination

Select the appropriate evaluation CPT code based on the following AND logic

Components for PT code selection: History; Examination using standardized tests and measures (count of elements as specified for level); Clinical presentation (stable/evolving/unstable); Clinical decision-making complexity; Development of a plan of care.PT: low=1-2 elements, moderate=3+ elements, high=4+ elements; typical face-to-face time guidance: low ~20 min, moderate ~30 min, high ~45 min

Therapist must define and document specific structures examined; personal factors that do not affect plan of care should not be used to increase level.

Components for OT code selection: Occupational profile and client history; Assessments of occupational performance (count of performance deficits); Clinical decision making; Development of plan of care.OT: low=1-3 deficits, moderate=3-5 deficits, high=5+ deficits; typical face-to-face time guidance: low ~30 min, moderate ~45 min, high ~60 min

Count of performance deficits is one factor; consider complexity of profile and clinical reasoning.

Components for AT code selection: History and physical activity profile; Examination; Clinical decision making; Development of plan of care.AT: low=1-2 elements, moderate=3+ elements, high=4+ elements; typical face-to-face time guidance: low ~15 min, moderate ~30 min, high ~45 min

Comorbidities, number of treatment options, and clinical presentation influence level selection.

inv-03: Billing Rules

Billing and unitization rules (ALL must be followed)

Billing constraints: Evaluation codes are untimed and billable as one unit; only one initial evaluation code should be used even if multiple complaints are evaluated; if an evaluation spans multiple days, bill one unit on the date the evaluation is completed; do not bill ROM tests or assistive technology assessment codes (CPT 95851-95852, 97750, 97755) on the same day as the initial evaluation; therapy screenings billed with evaluation codes are not covered; if treatment is provided same day as evaluation, bill treatment with appropriate CPT treatment codes and ensure documentation describes treatment separate from the evaluation.

If a new unrelated diagnosis arises later in the episode, another initial evaluation may be covered.

inv-04: Outcome Measures & Scope

Use of outcome measures and assessment scope

Outcome measures: Appropriate outcome measures should be used to quantify clinical and/or functional status and measure change over time (examples: Oswestry Disability Index, Neck Disability Index, Visual Analogue Pain Scale); refer to ASH resources for additional tools.

Outcome measures help assess effectiveness of interventions and prognostic indicators.

inv-05: Re-evaluation medical necessity

Re-evaluation services are considered medically necessary when ALL of the following are met:

Re-evaluation necessity: Re-evaluation is not a recurring routine assessment of patient status; documentation includes evaluation of progress toward current goals, a professional judgment about continued care, and a professional judgment about revising goals/treatment or terminating services; and an exacerbation or significant change in patient status or condition is documented.

Re-evaluations include data collection with objective measurements and use of standardized tests/measures as appropriate.

inv-06: SLP re-evaluation criteria

Speech-language pathology re-evaluation coverage:

SLP re-evaluation: Re-evaluation is covered only if documentation supports the need for further tests and measurements after the initial evaluation, requires the skills of the SLP, and is a distinct, separately identifiable service; it is not routine or recurring and is indicated for significant improvement, decline, or change in condition.

HCPCS S9152 exists but is not separately priced by Medicare Part B; some insurers may recognize it.

inv-07: E/M coding and medical decision making

Office/Other Outpatient E/M selection and medical decision making:

E/M selection methods: Select E/M level based on either total time spent on the date of encounter or level of medical decision making; if time is used, document total E/M time on the date of encounter; if basis is not specified, selection defaults to medical decision making and may be reconsidered with amended documentation showing time.

When time is used as basis and prolonged time occurs, appropriate add-on codes (e.g., 99417) may be reported.

Medical decision making elements: Medical decision making comprises number and complexity of problems addressed, amount/complexity of data to be reviewed and analyzed (tests, independent interpretations, interprofessional communications), and risk of complications/morbidity/mortality of management decisions; four levels recognized: straightforward, low, moderate, high.

MDM definitions per AMA CPT apply; concept does not apply to 99211.

inv-08: Initial Evaluations

Initial evaluations

Initial Evaluation Requirements: Initial evaluation must provide the basis for a working diagnosis; reveal occupational, social, and/or psychosocial issues that may impact care; identify comorbid or complicating factors; and establish the basis for an initial plan of care including the need for additional diagnostic testing and referrals.

Use the appropriate E/M series code supported for each case when applicable.

inv-09: Re-Evaluations / Established Patient E/M

Re-evaluations (Established patient E/M)

Core re-evaluation documentation: Re-evaluation is not a recurring routine assessment and documentation includes evaluation of progress toward goals, a professional judgment about continued care, and a professional judgment about revising goals/treatment or terminating services.

Indications for re-evaluation: At least one of: new clinical findings; significant change in the patient's condition; failure to respond to therapeutic interventions in current plan of care.

Re-evaluation is not considered medically necessary once maximum therapeutic benefit is reached unless valid reasons are documented.

Documentation sufficiency: An established patient E/M service without documentation of at least two of three required E/M elements (history, examination, level of medical decision making) cannot be approved; for specialty services (excluding Naturopathy and Podiatry) re-evaluations cannot be approved prospectively.

If re-evaluation is required after the fact, new examination findings must be submitted.

inv-10: MDM and Time-based E/M selection

Medical decision making and time-based code selection

MDM elements: MDM is defined by: (1) number and complexity of problems addressed; (2) amount/complexity of data to be reviewed and analyzed (tests, independent interpretations, interprofessional communications); and (3) risk of complications/morbidity/mortality of management decisions. Use AMA CPT definitions to select MDM level.

When reporting separate CPT codes that include interpretation/report, those interpretations should not be counted toward MDM for E/M selection.

Time-based selection: Total time on the date of encounter may be used to select Office/Other Outpatient E/M codes whether or not counseling/coordination dominates; document total time when used as basis for code selection; when prolonged time exceeds highest-level minimum by ≥15 minutes, report prolonged services add-on (e.g., 99417) as appropriate.

If basis for selection is not documented, selection defaults to MDM and may be reconsidered with amended documentation citing time.

Evaluations for deconditioning after hospitalization are not covered when the patient’s prior functional abilities are expected to spontaneously return through routine patient, caregiver, or nursing activities rather than requiring skilled therapeutic intervention. This exclusion applies to initial evaluation billing and reflects that such assessments do not meet the policy’s requirement that an initial evaluation document the medical necessity for a course of therapy with objective findings and a plan of care.

Evaluation and re-evaluation services may be non-covered when performed solely for maintenance, prevention, or wellness (including well-patient visits regardless of age), for pre-participation sports physicals, or for pre-employment physicals. Providers should confirm applicability against any client-specific summaries or benefit plan provisions before submitting claims for these purposes.

For specialty services (excluding Naturopathy and Podiatry), an established patient E/M service or re-evaluation cannot be approved prospectively (i.e., authorization for a future re-evaluation is not allowed). If a re-evaluation is later performed for a new problem or significant change, submission must include the new examination findings and documentation supporting the clinical need for that re-evaluation.

Therapy screenings are not billable when reported with evaluation codes. Screening assessments must be billed and documented as screenings and are considered non-covered if submitted using initial evaluation or re-evaluation CPT codes; do not substitute evaluation codes to report screening activity.

Routine, recurring reassessments that are part of each skilled treatment session (continuous assessment), progress reports, discharge summaries, administrative recertification, screenings, or other periodic/status updates are not considered re-evaluations for ASH payment and are not medically necessary as re-evaluation services. Re-evaluations must be distinct, clinician‑led assessments prompted by a documented clinical need (for example, an exacerbation or significant change in status).

A re-evaluation that is merely a routine, recurring assessment of patient status — without documentation showing evaluation of progress toward goals, a professional judgment about continued care, or a documented exacerbation or significant change — is not considered medically necessary. Re-evaluations require objective measurements and justification that they will alter the plan of care.

Coding and Time Guidance

Covered CPT Codes for PT/OT/AT EvaluationsCPTCovered

97161	Physical therapy evaluation, low complexity
97162	Physical therapy evaluation, moderate complexity
97163	Physical therapy evaluation, high complexity
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97169	Athletic training evaluation, low complexity
97170	Athletic training evaluation, moderate complexity
97171	Athletic training evaluation, high complexity

Re-evaluation CPT CodesCPTCovered

97164	Physical therapy re-evaluation
97168	Occupational therapy re-evaluation
97172	Athletic training re-evaluation

Initial Evaluation CPT ExamplesCPT

97161	PT Eval - low complexity (example)
97162	PT Eval - moderate complexity (example)
97163	PT Eval - high complexity (example)
97165	OT Eval - low complexity (example)
97166	OT Eval - moderate complexity (example)
97167	OT Eval - high complexity (example)
97169	AT/other Eval - low complexity (example)
97170	AT/other Eval - moderate complexity (example)
97171	AT/other Eval - high complexity (example)

Speech/Language Evaluation CPT CodesCPTCovered

92521	Evaluation of speech fluency
92522	Evaluation of speech sound production
92523	Evaluation of speech sound production with language evaluation
92524	Behavioral/qualitative analysis of voice and resonance
92610	Evaluation of oral and pharyngeal swallowing function

SLP Re-evaluation HCPCSHCPCS

S9152

Speech therapy re-evaluation (HCPCS 2017)

Office/Other Outpatient E/M CodesCPT

99202	Office/outpatient E/M new patient
99203	Office/outpatient E/M new patient
99204	Office/outpatient E/M new patient
99205	Office/outpatient E/M new patient
99211	Office/outpatient E/M established patient
99212	Office/outpatient E/M established patient
99213	Office/outpatient E/M established patient
99214	Office/outpatient E/M established patient
99215	Office/outpatient E/M established patient

Codes Not to Use for Re-evaluationsmixedNot Covered

97039	Unlisted modality — do not bill for re-evaluations
97139	Unlisted evaluation — do not bill for re-evaluations
97799	Unlisted PT/OT/SLP service — do not bill for re-evaluations
95851	ROM testing — not to be billed as re-evaluations
95852	ROM testing — not to be billed as re-evaluations
97750	Physical performance test — not to be billed as re-evaluations
97755	Assistive technology assessment — not to be billed as re-evaluations

New patient Office/Other Outpatient E/M CPT codesCPTCovered

99202	New patient E/M — Medical Decision Making = Straightforward; Time = 15-29 minutes
99203	New patient E/M — Medical Decision Making = Low; Time = 30-44 minutes
99204	New patient E/M — Medical Decision Making = Moderate; Time = 45-59 minutes
99205	New patient E/M — Medical Decision Making = High; Time = 60-74 minutes

Established patient Office/Other Outpatient E/M CPT codesCPTCovered

99211	Established patient E/M — Medical Decision Making = NA
99212	Established patient E/M — Medical Decision Making = Straightforward; Time = 10-19 minutes
99213	Established patient E/M — Medical Decision Making = Low; Time = 20-29 minutes
99214	Established patient E/M — Medical Decision Making = Moderate; Time = 30-39 minutes
99215	Established patient E/M — Medical Decision Making = High; Time = 40-54 minutes

Prolonged servicesCPTCovered

99417

Prolonged services add-on code for total time beyond highest-level E/M when time is basis for code selection; reported in 15-minute increments

Typical face-to-face time guidance — PT/OT/AT

PT typical face-to-face timeLow ~20 minutes; Moderate ~30 minutes; High ~45 minutes

OT typical face-to-face timeLow ~30 minutes; Moderate ~45 minutes; High ~60 minutes

AT typical face-to-face timeLow ~15 minutes; Moderate ~30 minutes; High ~45 minutes

Performance deficit counts for OT

OT low complexity

Provider Responsibilities, Documentation, and Billing Notes

Denial Risk

Claims and Coding Requirement

Claims submitted for services that are not accompanied by covered CPT diagnosis and/or procedure codes outlined in this policy will be denied as not covered. Providers must submit services using the most appropriate and current codes as of the date of service. Reimbursement is not allowed for services billed for conditions or diagnoses that are not covered under this policy.

Documentation Required

Required Documentation Elements for Evaluations and Re-evaluations

Initial evaluations and re-evaluations must include objective findings and subjective patient/caregiver report, assessment of progress and severity, and a professional judgment about continued care. Documentation should support medical necessity, show evaluation of progress toward goals, any revisions to the plan of care, and justify continued, modified or terminated services.

Document objective measurements and standardized tests when appropriate
Include assessment of progress toward current goals

Background

Initial evaluations establish whether skilled rehabilitative therapy or instruction is medically necessary by documenting objective findings and the patient/caregiver report, assessing severity and multi‑site or multi‑system involvement, identifying comorbidities and stability, and determining rehabilitation potential and an initial plan of care. Outcome measures (for example, Oswestry Disability Index, Neck Disability Index, Visual Analogue Pain Scale) are integral to quantifying baseline status and measuring change over time and should be included as appropriate in the initial evaluation documentation.

Definitions

Initial evaluation — Definition for initial evaluation by PT/OT/AT

DefinitionAn initial evaluation is the first encounter with the practitioner or practitioner group for a new injury/condition or the same/similar complaint after discharge; selection of code depends on level of complexity

Components used to select codeHistory; Examination (standardized tests/measures); Clinical decision-making; Development of plan of care

Covered CPT examplesPT: 97161–97163; OT: 97165–97167; AT: 97169–97171

Personal factors

Personal factors examplesSex, age, coping styles, social background, education, profession

Other personal factorsPast/current experience, behavior patterns, character

OpenPayer

Therapy Services Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations

Coverage Criteria for Evaluations and Re-evaluations

Coding and Time Guidance

Provider Responsibilities, Documentation, and Billing Notes

Background

Definitions