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Write an evaluation

warning

RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.

Use an evaluation to document the initial clinical picture, establish medical necessity, and create the plan of care for a therapy case.

Before you start​

Gather the information your organization expects for an evaluation:

  • medical and treatment diagnoses
  • prior level of function
  • current functional limitations
  • objective measures
  • goals
  • treatment frequency and duration
  • planned HCPCS codes or service types

Complete the evaluation​

  1. Open the patient's therapy case.
  2. Click Evaluation.
  3. Choose the correct template if more than one is available.
  4. Complete all required fields marked with an asterisk.
  5. Add diagnoses in the correct order.
  6. Enter the treatment plan, including frequency and duration.
  7. Select planned HCPCS codes under Anticipated treatment interventions when including a treatment plan.
  8. Save the evaluation.

For PT and OT treatment plans, Anticipated treatment interventions includes G0283, an untimed service for unattended electrical stimulation for indications other than wound care. Select it when that service is part of the planned treatment.

The service-code picker offers HCPCS codes valid on the evaluation date. Anticipated treatment interventions offers codes valid at any point during the treatment plan. Selected codes stay visible when dates change. If a service code is no longer valid on the evaluation date, the signature checklist asks you to replace or remove it before you sign.

After saving​

Review the case page to confirm that the evaluation, treatment plan, and scheduled treatments look correct. If physician or supervisor signature is required, send the document for signature.

You should know​

  • Evaluation date must be on or after the case start date. You can save a future evaluation for planning, but cannot sign it before its service date.
  • Cert start date must be on or after the evaluation date; it can be later.
  • Every medical or treatment diagnosis Onset date must be on or after the patient's date of birth, when known, and no later than either the evaluation date or today. Today is determined in the document's time zone. Secondary medical diagnosis onset dates remain optional.
  • If changing the evaluation date makes an entered onset or certification date invalid, correct that date before saving. RehabAlpha preserves the values for you to review.
  • If the case uses Evaluation weekday, its therapy weeks follow the initial evaluation date. Review the updated plan and schedule after changing that date. If an unsigned evaluation is deleted, the week remains pending until another evaluation is saved or a fixed weekday is selected.