Overview
Cohere believes in closely monitoring the patient’s responsiveness to therapy and condition progression and encourages periodic re-assessment of the patient’s need for therapy. While initial evaluations do not require authorization, being reevaluated for a separate issue constitutes a reevaluation which does require authorization.
Therapy evaluations and reevaluations
Initial evaluations
Evaluations, or initial evaluations, refer to the first evaluation in an episode. These do not require authorization and include the following CPT codes:
97161, 97162, 97163, 97165, 97166, 97167
Reevaluations
Per CMS, reevaluations are completed changes in patient condition or findings and are not part of the initial episode. These do require authorization and includes the following CPT codes:
97164, 97168
Should be submitted for the following:
New clinical findings
A significant change in the patient's condition
Failure to respond to the therapeutic interventions outlined in the plan of care
Untimed, one-off reevaluations (this means it should be requested as only one visit).
Should not be submitted for the following:
Part of routine, recurring services
Completing an updated plan of care
Recertification report
Progress report
Physician progress report
Initial and subsequent therapy requests (In the Cohere portal)
Initial therapy requests
The first therapy request in an episode, this may include multiple visits.
The initial therapy visit may be completed in conjunction with the initial evaluation, which does not require authorization, or it can be done separately during the next visit.
Subsequent therapy requests
The requesting of additional visits in the same episode where there is not a 60 day period between the first and second request.