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As therapy documentation requirements continue to tighten in 2026, re-evaluation, re-certification, and progress notes remain three of the most closely reviewed components across physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) practices.
These aren’t just documentation checkpoints. They directly impact medical necessity, compliance, reimbursement, and audit risk.
What Is a Re-Evaluation in Therapy?
A re-evaluation in therapy is a formal reassessment of a patient’s condition, progress, and response to treatment. Unlike daily treatment notes, a re-evaluation looks at the broader clinical picture and determines whether the current plan of care remains appropriate.
When Is a Re-Evaluation Required?
Re-evaluations are typically required when there is a significant change in patient status, including:
- Slower-than-expected progress or plateau
- New symptoms, diagnoses, or complications
- Regression in functional ability
- The need to modify goals or treatment approach
- Therapy extending beyond the original plan
In 2026, payers increasingly expect re-evaluations to reflect skilled clinical reasoning, not duplicated evaluation content.
How Re-Evaluations Affect Frequency of Care
A re-evaluation often results in changes to frequency or duration of care, such as:
- Increasing visits when progress slows
- Reducing frequency as goals near completion
- Extending care to address new impairments
All changes must be clinically justified and consistently documented.
Revising Goals During a Re-Evaluation
Re-evaluations are the appropriate time to:
- Discontinue goals that have been met
- Modify goals that are no longer appropriate
- Establish new short-term or long-term goals
Goals should remain functional, measurable, and patient-centered.
Why Re-Evaluations Matter for Compliance
From a compliance perspective, re-evaluations demonstrate that care is skilled, responsive, and medically necessary, rather than maintenance based.
What Is Re-Certification in Therapy?
Re-certification confirms that continued therapy remains medically necessary after the plan of care (POC) expires. It is commonly required for Medicare and Medicare Advantage patients
When Is Re-Certification Required?
Re-certification is required when:
- The plan of care reaches its expiration date
- Long-term goals extend beyond the original certification period
- Therapy must continue due to delayed or complex recovery
In 2026, payers expect re-certification notes to clearly justify why care must continue.
Adjusting Frequency and Goals During Re-Certification
Re-certification may involve:
- Updating visit frequency
- Extending the duration of care
- Modifying goals based on progress
Changes must align with functional need and objective findings.
The Role of ICD-10 and CPT Codes in Re-Certification
- Ongoing medical necessity
- Skilled intervention justification
- Claim approval and audit defense
Why Re-Certification Matters
Without proper re-certification, clinics risk denials, payment delays, and retroactive recoupments.
What Are Progress Notes in Therapy?
Progress notes summarize a patient’s response to care over time and assess whether treatment goals are being achieved.
They focus on trends, outcomes, and clinical judgment, not individual treatment details.
When Are Progress Notes Required?
Common payer requirements include:
- Medicare: At least once every 10 visits
- Commercial plans: Often at authorization expiration
Progress notes are a frequent target during audits.
What Should Progress Notes Include in 2026?
Effective progress notes should document:
- Functional improvement toward goals
- Objective outcome measures
- Skilled clinical reasoning
- Any changes to the plan of care
Generic or repetitive notes increase audit risk.
How Re-Evaluations, Re-Certifications, and Progress Notes Work Together
These three documentation elements form a continuous clinical narrative that demonstrates:
- Why therapy began
- How the patient is progressing
- Why continued care is medically necessary
Consistency across documents is critical in 2026.
How Modern Therapy Practices Manage These Requirements
Clinics that remain compliant long-term typically rely on systems that support:
- Discipline-specific documentation workflows
- Goal-driven progress tracking
- Plan-of-care alignment across visits
- Audit-ready documentation without added administrative burden
Frequently Asked Questions (FAQ)
Q1. What is the difference between re-evaluation and re-certification?
A re-evaluation reassesses progress and clinical direction. Re-certification confirms continued medical necessity after the plan of care expires.
Q2. Are re-evaluations required for all patients?
They are required when there is a significant change in condition or need to adjust the plan of care.
Q3. How often are progress notes required?
Medicare requires them at least every 10 visits. Commercial plans vary by authorization rules.
Q4. Can poor documentation lead to denials?
Yes. Inconsistent goals, weak medical necessity, and repetitive language are common denial triggers.
Q5. How can clinics stay compliant in 2026?
By maintaining clear clinical reasoning, accurate coding, consistent documentation, and therapy-specific workflows.
