What is required for reimbursement in private practice?

• A. Must document every visit and complete re-evals at least every 30 days
• B. Documentation is optional if patient agrees
• C. Re-evaluation every 90 days
• D. Only initial evaluation is needed

Answer: (A)

Documentation for every visit and a formal re-evaluation at least every 30 days is required for reimbursement in private practice. Each visit should be accompanied by notes detailing what was done, the patient’s response, and any changes to goals or prognosis. The periodic re-evaluation provides a structured reassessment of function, progress toward goals, and updates to the plan of care, showing ongoing medical necessity for continued skilled therapy. Without consistent visit documentation and timely re-evaluations, payers may deny claims because there’s insufficient evidence of ongoing need. The initial evaluation establishes baseline and goals, but sustained reimbursement relies on ongoing documentation and reevaluations to justify continued care.