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Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. The tests and measures may be repeated from the initial examination, or the PT may introduce new elements of tests and measures to evaluate the individual's status. Reexamination may be indicated more than once during a single episode of care and for a number of reasons. However, due to certain payer regulations, many therapists confuse a clinical reexamination with a billable reevaluation code. In general, a billable reexamination of a patient or client should occur whenever there is an unanticipated change in the individual's status, a failure to respond to physical therapist intervention as expected, the need for a new plan of care, or requirements based on state practice acts or other requirements.
In clinical practice, a reexamination and reevaluation can serve many purposes. One of the most important objectives of the reexamination is to determine the patient's or client's progress or lack of progress toward the established goals and prognosis. The reevaluation compares similar data at 2 points in time and determines whether or not the plan of care needs to be updated or changed and how this will affect the expected outcomes and timeframe of care.
Physical therapist goals should be addressed noting where progress has (or has not) been demonstrated. If appropriate, new timeframes and new goals should be established, as well as confirmation of the clinical evaluation or impression, prognosis, and conclusion of care recommendations. If progress has not occurred as expected, reasons for the lack of progress should be included (eg, illness or comorbidity). In addition, any changes to the interventions should be documented. Only the physical therapist can perform and record a reexamination.
It is recommended to document vital signs (eg, blood pressure, heart rate, respiratory rate, or pulse oximetry), as well as to record any medication changes with implications for functional recovery. These data may contribute to the information gathering for the MDS in skilled nursing facilities.
For Pediatric Patients and Clients
In most cases in pediatric early intervention, the comprehensive team reexamination report is required annually as part of the formal team review of eligibility for services and review of the IFSP. In school-based practice, comprehensive team reexamination, reevaluation, and reassessment for the integrated educational assessment are performed every 3 years or as mandated by state and federal regulations (eg, Individuals with Disability Education Improvement Act of 2004). This is a minimal requirement and may be done more frequently as indicated by the pediatric patient's change of status, parent request, and team decision; or by any requirements of individual state practice acts.