These terms are often misunderstood and mistakenly used interchangeably. This guide clarifies the differences between them, when to use each, and how to complete these actions in PatientStudio.
Re-Evaluation
A re-evaluation is a formal assessment performed when a patient's condition changes significantly—either improving, declining, or deviating from the expected progression in a way that requires modifying therapy goals and interventions. This reassessment is necessary when there is a "change in status" beyond the anticipated recovery timeline.
When to Perform a Re-Evaluation
The patient shows unexpected improvement or decline.
New symptoms or complications arise that were not anticipated in the initial treatment plan.
A significant change in functional status occurs, requiring goal modifications.
How to Perform a Re-Evaluation in PatientStudio
Use the “Evaluation” template to conduct a formal reassessment.
Document the patient’s new status and update therapy goals accordingly.
Add the re-evaluation CPT code (97164) to the documentation.
How to add re-eval CPT code
How to add re-eval CPT code
1. Under Suggested Charges, Click "+ Add procedure code(s)"
2. Search 97164 and Click "Add"
Progress Note
A progress note tracks the patient’s response to therapy, documenting improvements, stagnation, or setbacks. While progress notes often involve re-measuring and reassessing the patient, they are not the same as a re-evaluation unless an unexpected change in status occurs.
Key Differences Between a Progress Note and a Re-Evaluation
Progress notes are routine check-ins on therapy progress.
Re-evaluations are only needed if the patient’s condition changes in an unanticipated way.
A progress note is not billable as a re-evaluation.
How to Perform a Progress Note in PatientStudio
Select the "Progress Note" note type.
Record relevant updates on the patient’s therapy progress.
Perform measurements and standard assessments as needed.
Where to find and start progress notes
Where to find and start progress notes
1. From Provider Dashboard, Click pencil icon icon.
2. Click "Progress Note"
Re-Certification
When an initial assessment is completed, a Plan of Care (POC) is created, outlining:
Goals for the patient
Planned treatments
Treatment frequency
Duration of the plan
Why is Re-Certification Required?
Medicare limits treatment plans to 90 days, meaning a new plan must be created at the end of each period.
Even if the treatment plan remains unchanged, providers must re-certify that it is still appropriate for the patient's needs.
The best time to assess the necessity of a new plan is during a progress note, as it naturally includes patient updates.
How to Re-Certify a Plan of Care in PatientStudio
Click here to learn how to recertify a POC in PatientStudio.
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