Learn about the key procedures of re-evaluation, re-certification, and progress notes in therapy to ensure effective, compliant care across PT, OT, and SLP practices.
What is Re-Evaluation?
Re-evaluation is a key part of therapy that ensures the care provided meets the patient’s changing needs. Patient progress is often unpredictable; some patients improve quickly, while others may experience setbacks or reach plateaus. Re-evaluation helps therapists reassess the treatment plan, adjust goals, and make changes to keep therapy on track.
When Do You Need to Re-Evaluate?
Re-evaluations are necessary whenever a patient’s condition changes significantly. If a patient is not making expected progress, hits a plateau, or shows new symptoms, it’s time to reassess. Re-evaluation is also important if therapy extends beyond the original plan of care to ensure treatment continues to meet the patient’s evolving needs.
Adjusting Frequency of Care
After a re-evaluation, the frequency of therapy sessions may need adjustment. For example, if a patient is not improving as expected, you may decide to add an extra session each week or extend the therapy duration. Sometimes, extending therapy for a few more weeks may be needed to reach the patient’s goals and address any new challenges.
Revising Goals
Re-evaluation is also an opportunity to revisit a patient’s goals and ensure they remain realistic and achievable. If necessary, new short- and long-term goals can be set that reflect the patient’s current status. For example, a focus might shift to improving functional goals, such as walking longer distances, regaining balance, or performing more complex tasks.
Why Re-Evaluations Matter
Re-evaluations are crucial for ensuring therapy is relevant and effective. They allow therapists to adjust the treatment plan and goals based on the patient’s progress. This process ensures that therapy continues to be responsive to the patient’s changing needs, maximizing their potential for success.
What is Re-Certification?
Re-certification ensures that continued therapy is still necessary for a patient’s progress. It’s required when the Plan of Care (POC) expires and often involves approval from a referring physician or specialist, rather than directly from Medicare.
When is Re-Certification Needed?
Re-certification typically occurs when the POC expires. This may happen before the standard 90-day mark, depending on the goals and frequency set. If long-term goals (LTGs) are established with specific durations, such as 60 or 90 days, and progress is slower than expected, re-certification allows therapy to continue without interruption. It ensures the treatment plan remains aligned with the patient’s needs.
Adjusting Frequency of Care and Goals
Like re-evaluation, re-certification can also involve adjustments to the frequency of therapy. For example, the number of therapy sessions per week may need to be increased, or the treatment duration may be extended if progress is slower than expected. Based on the results of the re-assesment, therapists can modify the POC, set new goals, and develop an updated treatment plan in the recertification note.
The Role of ICD-10 and CPT Codes
ICD-10 and CPT codes are crucial during re-certification. These codes are used to justify the ongoing need for therapy, ensuring that the diagnosis and treatment align with the patient’s progress. When submitting for re-certification, be sure to review and update these codes as needed to reflect any changes in the patient’s condition or treatment approach.
Why Re-Certification Matters
Re-certification ensures that therapy remains necessary and appropriate for the patient. It provides an opportunity to review goals, adjust treatment plans, and modify the frequency or duration of therapy. This ensures that therapy remains effective and compliant with regulatory guidelines.
What are Progress Notes?
Progress notes are essential for documenting a patient’s progress and the effectiveness of their treatment. Unlike daily notes, which are written after each session, progress notes are completed at specific intervals. For Medicare patients, progress notes are done at least once every 10 sessions, while for insurance patients, they are written when the authorization expires, and the new one is needed.
Progress notes summarize a patient’s achievements, document any progress made towards the treatment plan, and outline future goals. These notes play a key role in ensuring compliance with insurance requirements and facilitating communication with insurance providers.
Progress notes are also essential for tracking long-term progress. They help assess whether therapy goals are being met and if the treatment plan needs adjustment.
Conclusion
Re-evaluation, re-certification, and progress notes are all essential parts of therapy. Re-evaluation ensures that therapy remains effective by adjusting goals and frequency to meet the patient’s changing needs. Re-certification ensures therapy continues to be medically necessary and compliant with Medicare guidelines. Progress notes provide a clear record of the patient’s progress and ensuring compliance with insurance companies.
By following these processes in platforms like HelloNote, therapists can provide the best possible care, keeping therapy relevant, effective, and compliant across all practices, whether PT, OT, or SLP. With HelloNote, therapists can efficiently track and document these essential elements, streamlining their workflow while maintaining high standards of care.