Initial Therapy Evaluations
Key points to know for your initial therapy evaluation.
PTAS/COTAS YOU CAN SKIP THIS ONE
Key Points:
Schedule 90 Minutes for Your Initial Evaluation: This will include evaluation (a minimum of 15 minutes) and a treatment session. Note that UHC patients are only 60 minutes.
What to Bring: Be sure to bring PPE, a gait belt, and a blood pressure cuff!
Before You Leave: Schedule the patient's next appointment. LifeCare uses a 3-week rule for scheduling, meaning that you should be seeing the patient for a supervisory visit every 3 weeks, regardless of POC frequency.
Communicate to the PTA/COTA: Notify the assistant (if assigned) that the evaluation is complete and provide an overview of the treatment plan. Many therapists do this directly at the patient's home so both assistant and patient are aware or use HUCU.
Evaluation Templates
Each therapy discipline has a "default" template for the initial evaluation with default assessment tools and content. Alternative evaluation templates for specific musculoskeletal disorders are also available and may be used when appropriate. You can learn more about those here
Evaluation Complexity:
PT/OT Evaluation Codes are based on complexity with a worksheet included in the Initial Evaluation Template for each discipline. Evaluations are always coded at the lowest level of complexity (i.e., if one requirement is "Low", the evaluation is considered a "Low Complexity Evaluation").
Regulatory Guidelines
Only a clinician (PT, OT, SLP) may perform an initial therapy evaluation. The initial therapy evaluation will document the necessity for a course of therapy through objective findings and subjective patient self-reporting and will be used, when not provided by the physician, to develop a comprehensive plan of care for the patient. The therapist shall utilize the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech-Language and Hearing Association for the components of the evaluation, but not as policy. In compliance with accepted standards of professional practice, the Evaluation & Plan of Treatment must demonstrate:
The services to be provided are specific and effective treatment for the patient’s condition, and are of a level of complexity such that the services can only be safely and effectively performed by a qualified therapist or assistant.
A loss of prior levels of function together with a realistic expectation that the patient’s condition will improve significantly in a reasonable period of time or that the services are necessary to establish a safe and effective maintenance program (see section on Maintenance for additional details).
The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.