A Medley of Frequently-Asked Compliance Questions

Students raising hands in a classroom
By Mary R. Daulong, PT


Where do I locate the required content of the Re-evaluation CPT code 97164?

There are two references you should use to assist you in your re-evaluation documentation and rationale for billing the 97164 CPT code. The first is Medicare’s Benefit Policy Manual, Chapter 15 Section 220.3 C, and the second is the AMA CPT Coding Book.

Unfortunately, the re-evaluation CPT code 97002 requirements have not been updated in the Medicare Benefit Policy Manual since 2014 and, as you know, that re-evaluation CPT code was retired and replaced with CPT code 97164 in 2017; it has additional rationale and associated documentation requirements.

The 97002 CPT code for re-evaluation, as defined in the Medicare Benefit Policy Manual, states that:

“A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.

Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations. Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.

A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.

Indications for a re-evaluation include:

  • New clinical findings
  • A significant change in the patient’s condition
  • Failure to respond to the therapeutic interventions outlined in the Plan of Care

A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.

A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services.

Re-evaluation requires the same professional skills as evaluation. The minutes for re-evaluation are documented in the same manner as the minutes for evaluation.

The physical therapy re-evaluation CPT code 97164, per the AMA, must include the following:

  • An examination utilizing standardized tests and measures.
  • A review of the patient’s history.
  • A revised plan of care utilizing a standardized patient assessment instrument and or a measurable assessment of functional outcome.

Since we are obligated to comply with the Medicare Benefit Policy Manual content until, otherwise directed, it would be prudent to include the criteria from both authorities.


We received a letter from Medicare stating, “Additional Documentation Required.” Is this an audit?

There are many reasons for a request for records from Medicare and, typically, it is because of their need to assess your documentation for payment justification. The contractor must identify itself and the type of review in its letter. Once you review the letter you should be able to ascertain whether the request was predicated on data analysis, a complaint, a random selection of providers, etc.

Contractors authorized to review patient records are required to send a letter or fax which includes:

  • Name and address of the selected provider/supplier
  • Date
  • Case number
  • Provider NPI
  • Contractor’s authorization to access records
  • Type of review
  • Reason for selection
  • Explanation of the process
  • Action required by the provider/supplier
  • Consequences for non-response
  • Submission information requirements
  • Submission address

The following illustrates a partial example of correspondence from the Comprehensive Error Rate Testing Program Contractor:

Dear Medicare Provider/Supplier,

The Centers for Medicare & Medicaid Services (CMS), through the Comprehensive Error Rate Testing (CERT) program, carries out the task of requesting, receiving, and reviewing medical records.1 The CERT program reviews selected Medicare A, B and DME claims and produces annual improper payment rates. For more information regarding the CERT program, please visit www.cms.gov/CERT.

Reason for Selection: The CMS’ CERT program has randomly selected one or more of your Medicare claims for review.

Action: Medical Records Required

Federal law requires that providers/suppliers submit medical record documentation to support claims for Medicare services upon request. Providers/suppliers are required to send supporting medical records to the CERT program. Providing medical records of Medicare patients to the CERT program does not violate the Health Insurance Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to this request. Providers/suppliers are responsible for obtaining and providing the documentation as identified on the attached Bar-coded Cover Sheet. The CMS is not authorized to reimburse providers/suppliers for the cost of medical record duplication or mailing. If you use a photocopy service, please ensure that the service does not invoice the CERT program.

Most record reviews are targeted based on billing behavior or similar, which can easily be determined at the claims level. The CERT Program is an exception as its selection is random.

The best way to minimize your risk during an audit or review, besides complying with Medicare billing, coding and documentation requirements, is to excel in your records submission procedure.

Tips to Assist with the Request for Additional Documentation (ADR)

  • Copy the entire letter and retain the envelope.
  • Make two or more copies (one to accompany the ADR and one for your file).
  • Review the letter for deadlines, type of audit, and directions relating to what records are to be submitted to the contractor.
  • Review and cross check patient records for completeness (e.g., signed Plans of Care, etc.).
  • Organize each patient record set in an identical manner.
  • Secure the records and ship them using a reliable vendor with tracking capabilities and verify receipt of the documents shipped.
  • Monitor status regularly.

For more information about audits and for detailed ADR submission guidance, please see the February 2021 issue of my Impact article entitled The Administrative Burden and Mental Stress of an Audit.


Is it required by law that I perform an OIG List of Excluded Individuals verification?

No, it is not a legal requirement to check the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE). The LEIE list encompasses individuals and entities, that for various reasons, have been excluded from the federal program. It would be very wise to check the list, as a pro-active measure, to verify that services you provide are not reimbursed, directly or indirectly in association with an individual or entity that has been excluded by the OIG.

Civil Monetary Penalties of up to $10,000 for each item or service furnished by the excluded individual or entity for Federal program reimbursement. Additionally, there may be an assessment of up to three (3) times the amount claimed, as well as the potential program exclusion.

In the May 8, 2013, Special Advisory Bulletin (SAB), the US Department of Health and Human Services Office of Inspector General (OIG) said that providers are free to set the frequency or instances wherein they have to check their employees, contractors, or new hires to ensure that they have not been excluded from participation in federal health programs. Please note that certain states require monthly monitoring of their Medicaid exclusion list, so it is paramount to know what your state mandates.

Recommendations for Screening Frequency

  • All prospective employees/independent contractors—upon job offer and, monthly for the first six months
  • Current employees—no less than annually and more frequently if “moonlighting”
  • New graduates with federal health care loans (subject to program exclusion, if they default on the loan)—monthly
  • Active referrers and vendors; upon the first referral or business dealings and then—annually
  • Students—upon onset of clinical assignment


Is it necessary to inform Medicare if I add or change a practice location or have other practice or profile changes?

Yes, Medicare has very specific requirements regarding maintaining an accurate accounting of group and supplier/provider enrollment profiles.

Medicare states that unless, otherwise directed, the following situations require updates within these specified time period:

medicare time period table

**Please note: Therapists that bill under assignment (using the 855r) to a group practice will cease to be paid for services rendered after the death of the group practice’s owner/authorized individual.


Do I need to discharge a patient under a restorative/rehabilitation Plan of Care to move him/her into a skilled maintenance therapy program?

The Medicare Benefit Policy Manual does not stipulate that a discharge or a discharge report be performed when a patient is transitioned from restorative therapy to skilled maintenance therapy. However, the Plan of Care must be updated to reflect new maintenance therapy goals for the patient. The Plan of Care must be certified within thirty (30) days of the transition and then recertified every ninety days for the duration of episode of care.

Maintenance therapy is a covered service if it is necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided. The health care provider must continually evaluate the individual’s need for skilled care and document adequately to justify that services are reasonable and necessary to treat the individual’s condition on a prospective basis.


I am contracting with a temporary physical therapist for the summer to cover vacations. Can I bill for her services under my NPI, if I co-sign her documentation?

Medicare requires therapists to be enrolled in the Medicare program in order to bill for services rendered. Medicare does permit a therapist to treat Medicare patients while waiting for enrollment confirmation, but all associated claims must be held until the therapist receives notice of enrollment confirmation and is awarded a Medicare number (PTAN i.e., Provider Transaction Access Number). An enrolled therapist’s co-signature is not required by Medicare for a qualified therapist awaiting enrollment validation and its presence does not provide an exception to the requirement of mandatory enrollment prior to billing.

If an enrolled therapist bills for services provided by a non-enrolled therapist, he/she could be implicated in a False Claims Act violation. The penalties are levied for each violation or false claim with a minimum penalty per claim of $11,665 and a maximum penalty per claim of $23,331 plus three times the actual billed amount.


I live in Texas, and I am joining a physical therapy company as a traveling therapist. Can I treat patients New Mexico, Oklahoma, Louisiana and Kansas without a license in those states?

It appears you are asking if the Physical Therapy Licensure Compact privilege in the Texas Practice Act and Rules permits treatment across borders. Texas, along with twenty other states, is a member of the PT Compact. The states that are members as of July 1, 2021, are: Arizona, Colorado, Iowa, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, Tennessee, Texas, Utah, Washington, and West Virginia.

To exercise the PTLC privilege all states in which you practice, including your home state, must be in the Physical Therapy Compact. So, to answer your question, yes you may practice in Oklahoma and Louisiana under the PTLC, however, you must be licensed in New Mexico and Kansas in order to legally practice physical therapy.


Who must or may sign a Progress Report for a Medicare patient? The physical therapist, the physical therapist assistant, and or the patient’s attending physician?

Medicare requires the signature of the physical therapist who crafted the progress report to be dated and documented, including his/her professional designation. The therapist must render all assessments and clinical decisions required for the progress report.

While the physical therapist assistant may collect objective and subjective information for the therapist, the assistant should not sign the progress report. The therapist may make a notation such as “Joe Green, PTA, assisted in data collection for this report.” Progress reports do not have to be sent to nor signed by the patient’s attending physician unless the progress report serves as a plan of care and certification/ recertification is needed. The components of both reports must be documented when used in combination.


I have professional colleagues who do not complete their documentation for weeks. Is there a law that states when you must complete your daily notes, etc.?

While some payers have documentation timelines you must also look to your practice act and rules for documentation requirements which can include timeframes. You must defer to the most stringent requirement to be in full compliance. The Medicare Benefit Policy Manual Chapter 15, Section 220.3 B addresses documentation as follows:

The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan.

However, contractors (MACs) may require that treatment notes and progress reports be entered into the record within one (1) week of the last date to which the progress report or treatment note refers.

I highly recommend that your practice establish documentation timelines in policy, so all therapists know what expectations and requirements prevail. The accuracy of documentation, typically, is diminished when not promptly recorded. This could result in patient care compromises as well as legal liabilities.


I am new to the billing department and need to understand what MPPR is to know its impact on our Medicare payments.

Medicare applies a multiple procedure payment reduction (MPPR) to the practice expense (PE) payment of select therapy services. The reduction applies to the Healthcare Common Procedure Coding System codes contained on the list of “always therapy” services, regardless of the type of provider or supplier that furnishes the services.

The MPPR is applied to the PE payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures.

Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR applies to all therapy services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines such as, physical therapy, occupational therapy, or speech-language pathology.

Payment calculation under the MPPR System is conducted in the following manner. Each CPT code has a relative value unit (RVU) assigned to it. The RVU for each code is subject to a geographical adjustment (Geographic Practice Cost Indices or GPCI) and then it is multiplied by the Medicare conversion factor (CF).

The RVUs have three resource-based components (resource-based Relative Value Scale or RBRVS):

  • Physician/provider Work Expense (PW) which takes into consideration the level of time, skill, training, and intensity to provide a given service ~52%
  • Practice Expense (PE) which addresses the costs of maintaining a practice, i.e., non-physician/provider labor, rent, equipment, supplies, etc. ~44%
  • Professional Liability Expense (PL) accounts for the cost of malpractice insurance ~4%

Under the Multiple Procedure Payment Reduction system:

  • Full payment is made for the unit with the highest Practice Expense (PE)
  • Subsequent units furnished to the same patient on the same day, are paid at 50% of their PE while PW & PL for those codes are paid at 100%

CPT codes should be ranked according to their PE RVU unless two or more units have the same PE value. In this case, the unit with the highest total value (PW + PE + PL) will be paid at 100%. Only one unit can be paid at 100% of its relative value.


Am I compliant with Medicare’s requirement for signed plans of care if I am unable to obtain a certified plan after making three attempts to get it signed by the patient’s physician?

Medicare’s plan of care certification is a statutory requirement in SSA 1835(a)(2). Claims paid for services delivered without a certified Plan of Care should be refunded to Medicare within 60 days of discovering the absence of certification.

If a provider cannot produce a plan of care (timely or delayed) for the billed treatment dates certified by a physician/non-physician practitioner, it falls under the technical denial provision and will result in recoupment of monies by Medicare unless the technical denial decision is reopened by the contractor or reversed on appeal as appropriate if delayed certification is later produced.

Services furnished by a rehabilitation agency preclude the provider from charging the beneficiary for services denied as a result of missing certification. However, if the service is provided by a Part B therapist in private practice, a technical denial due to absence of a certification results in beneficiary liability. For that reason, it is recommended that the patient be made aware of the need for certification and the consequences of its absence prior to commencing physical therapy treatment.

Invoking the patient’s assistance to obtain the certified plan of care is often successful because the patient can appeal, directly, to the physician regarding the technical denial’s financial ramifications without his/her signature on the plan. 


1Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual Chapter 15, Sections 220-233 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673

2Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual Chapters 1, 5, 8, 30, and 34. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912

3Medicare Program Integrity Manual Chapters 2, 6, 9, 10,15, and Exhibits. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033

4Centers for Medicare and Medicaid Services. Medicare Maintenance Therapy. https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQs.html

5US Department of Health and Human Services. Office of Inspector General Exclusion Program. https://oig.hhs.gov/exclusions/

6Physical Therapy Licensure Compact. http://ptcompact.org/ptc-states

Mary R. Daulong

Mary R. Daulong, PT, is a PPS member and is the CEO/President of Business & Clinical Management Services, Inc. a compliance consulting firm. She may be reached at daulongm@bcmscomp.com.

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