Let's be honest: therapy billing can feel like navigating a maze blindfolded. Between keeping track of CPT codes, knowing when to bill (and when not to), and making sure your clinical documentation supports every claim, it's no wonder so many therapy clinics struggle to stay on top of their revenue cycle.
But here's the good news: once you understand the fundamentals, therapy billing solutions become much more manageable. Whether you're running a physical therapy practice, an occupational therapy clinic, or a speech-language pathology office, this guide breaks down the three essential documentation types you encounter daily: re-evaluations, progress notes, and follow-up sessions.
Let's simplify the process together.
Understanding the Three Pillars of Therapy Documentation
Before we dive into the specifics, it's important to understand that not all documentation is created equal when it comes to billing. Some documentation directly generates revenue, while other types exist purely to justify and support ongoing care.
Here's the breakdown:
- ✅ Re-Evaluations – Billable under specific circumstances
- ✅ Progress Notes – Required but NOT separately billable
- ✅ Follow-Up/Daily Treatment Notes – Where the bulk of your billing happens
Getting these right means fewer denials, faster reimbursements, and more time focusing on what you do best: helping your patients recover.
Section 1: Re-Evaluations (Re-Evals)
What's the Purpose?
A re-evaluation allows you to reassess your patient's progress and modify the Plan of Care (POC) as needed. These aren't routine check-ins: they're clinically driven assessments required at specific intervals or when there's a significant change in the patient's status.
Think of it this way: If your patient has plateaued, regressed, or made unexpected gains, a re-eval helps you recalibrate the treatment plan and document why continued care is medically necessary.
CPT Codes by Discipline
Here's where it gets discipline-specific:
| Discipline | CPT Code | Description |
|---|---|---|
| PT | 97164 | Re-evaluation of physical therapy established plan of care |
| OT | 97168 | Re-evaluation of occupational therapy established plan of care |
| SLP | 92597 (less common) | Re-evaluation of speech-language function |
Important Note for SLPs: Speech-language pathologists typically don't have a distinct CPT code for re-evaluations. In many cases, SLPs may bill 92523 (the evaluation code) again if clinically justified, with thorough supporting documentation. Always check payer-specific guidelines before submitting.
When to Bill a Re-Eval
This is where many clinics run into trouble. Re-evaluation codes should only be used when:
- ✅ The re-evaluation is clinically necessary
- ✅ Updated objective testing is included
- ✅ It's not just a routine or scheduled review
Many insurers require clear justification for re-evals. If your documentation doesn't support medical necessity, expect a denial. Strong clinical documentation is your best defense against rejected claims.
Section 2: Progress Notes
What's the Purpose?
Progress notes summarize how your patient is tracking toward their established goals. They're a critical piece of the puzzle for ongoing care justification, especially when dealing with Medicare and other major insurers.
The Billing Reality
Here's what catches many clinics off guard: progress notes are not separately billable.
There's no CPT code for a progress note. Instead, they serve as required documentation that accompanies your regular billed treatment codes. Think of them as the supporting evidence that justifies why you're continuing care.
Timing Requirements
For Medicare patients (and many commercial payers), progress notes are typically required:
- 📅 Every 10th visit, OR
- 📅 Every 30 days: whichever comes first
Missing these deadlines can result in claim denials and payment delays. Building a reliable tracking system: whether through your EHR or a simple spreadsheet: helps ensure nothing slips through the cracks.
What to Include
Your progress notes should clearly document:
- ✅ Progress toward established goals
- ✅ Any barriers to progress
- ✅ Updated objective measurements
- ✅ Justification for continued treatment
- ✅ Any modifications to the treatment plan
When insurers review your claims, they're looking for proof that ongoing therapy is medically necessary. Your progress notes provide that proof.
Section 3: Follow-Up and Daily Treatment Notes
What's the Purpose?
This is where the bulk of your billing happens. Follow-up notes (also called daily treatment notes) capture exactly what was done during each session. They're required to support billing for every single visit.
CPT Codes for Routine Treatment Sessions
Here's a quick reference for the most common codes used during daily treatment:
| Discipline | CPT Code | Description |
|---|---|---|
| PT/OT | 97110 | Therapeutic exercise |
| PT/OT | 97530 | Therapeutic activities |
| PT/OT | 97112 | Neuromuscular re-education |
| PT/OT | 97116 | Gait training |
| PT/OT | 97535 | Self-care/home management training |
| SLP | 92507 | Individual speech therapy session |
| SLP | 92523 | Evaluation of speech/language and speech sound production |
| SLP | 92526 | Treatment of swallowing dysfunction |
Pro Tip: For initial evaluations (not follow-ups), PT uses codes 97161–97163, and OT uses 97165–97167. Don't mix these up with your treatment codes.
Documentation Must Support Medical Necessity
Every session you bill must be backed by documentation that demonstrates:
- ✅ What services were provided
- ✅ How long the session lasted (especially for time-based codes)
- ✅ Why the treatment was medically necessary
- ✅ How it connects to the patient's goals
Time-based codes are especially scrutinized. If you're billing for 45 minutes of therapeutic exercise, your documentation needs to reflect that time was actually spent: and what specifically was accomplished.
Putting It All Together: Best Practices for Clean Claims
Now that you understand the differences between re-evals, progress notes, and daily treatment documentation, here are some practical tips to keep your medical billing services running smoothly:
1. Build a Documentation Calendar
Track when progress notes are due for each patient. Whether it's every 10th visit or every 30 days, staying ahead of deadlines prevents last-minute scrambles and missed requirements.
2. Train Your Team on Code Selection
Ensure every therapist understands which CPT codes apply to which services: and when a re-eval is appropriate versus a standard treatment session.
3. Audit Regularly
Periodic internal audits help catch documentation gaps before they become claim denials. Look for missing signatures, incomplete notes, and unsupported time entries.
4. Leverage Technology
Practice management software and EHR systems can automate reminders, flag incomplete documentation, and streamline claims submission. The right tools save hours of administrative headaches.
5. Partner with Billing Experts
Sometimes the smartest move is bringing in specialists who live and breathe therapy billing. A dedicated therapy billing solutions partner can identify revenue leaks, reduce denials, and free your team to focus on patient care.
The Bottom Line
Therapy billing doesn't have to be overwhelming. When you understand the purpose behind each documentation type: and know exactly when and how to bill: you gain confidence in your revenue cycle and peace of mind knowing your claims are clean.
Quick recap:
- Re-Evaluations = Billable when clinically necessary (CPT 97164, 97168, 92597/92523)
- Progress Notes = Required documentation, NOT separately billable
- Daily Treatment Notes = Where your revenue lives (97110, 97530, 92507, etc.)
Strong clinical documentation ties everything together. Without it, even the correct CPT code won't save you from a denial.
Ready to Streamline Your Therapy Billing?
Ready to stop stressing over the paperwork and start focusing on your patients? Contact ALS Integrated Services, LLC at www.alsintegratedsvc.com or call Rachel at 513-597-1358 today.