PT re-evaluation and progress reports for Medicare

For physical therapists treating Medicare Part B outpatients: write a progress report at least once every 10 treatment days, re-evaluate only for new findings, a significant change or a failure to respond, keep the plan certified for at most 90 days at a time, and add the KX modifier above $2,480 in 2026.⁠^1,2,3,4

What does Medicare require in a PT progress report?

A progress report written by the clinician at least once every 10 treatment days, which justifies the medical necessity of the treatment in that period.⁠¹ The rule sits in the Medicare Benefit Policy Manual, chapter 15, section 220.3, and it applies to physical therapy, occupational therapy and speech-language pathology furnished under Part B alike.⁠¹

The count is of treatment days, not calendar days. The first reporting period starts on the first day of the episode, whatever service was given that day, and days on which the patient sees no qualified professional or qualified personnel do not count as treatment days.⁠¹ Absences do not remove the requirement for one report in each period.⁠¹

The manual’s own example: a patient evaluated on Monday, October 1 and treated five times a week, whose clinician writes an early report on October 5, needs the next report to cover October 8 through October 19, which is 10 treatment days.⁠¹ A clinician may report more often; the manual encourages it, and each report ends one period and starts the next.⁠¹

What must a clinician’s progress report contain?

The dates of the reporting period, the date written, the writer’s signature and professional identity, relevant patient statements, and objective measurements or descriptions of change for each goal, plus three elements only a clinician supplies.⁠¹ Those three are an assessment of improvement or its absence toward each goal; plans for continuing treatment, further evaluation results or plan revisions; and any change to goals, a discharge, or an updated plan sent for certification of the next interval.⁠¹

The manual is specific about what counts as objective: "increasing strength" is not an objective measurement, while "patient ambulates 15 feet with maximum assistance" is.⁠¹ It also warns that reports written at the minimum frequency need particular care to justify the services of the whole period.⁠¹

What counts as the therapist’s active participation in a period?

Personally furnishing, in its entirety, at least one billable service on at least one treatment day of the period; a reporting period is complete only when both the report’s elements and that participation are documented.⁠^1,7 If the therapist did not participate during the period, the delayed participation is entered in the treatment note as soon as possible, with the reason it was missed.⁠¹

Can a PTA write the Medicare progress report?

No. A physical therapist assistant may write elements of a progress report dated between the therapist’s reports, but those are not complete progress reports, and the therapist must write one in every period.⁠¹ Assistants report progress objectively; the clinical judgment about why progress was or was not made stays with the therapist.⁠¹

Is functional G-code reporting still required in progress reports?

No. The manual still describes functional reporting in its progress report section, but a note in its definitions states that functional reporting requirements no longer apply to claims for dates of service on and after January 1, 2019.⁠⁷

When is a PT re-evaluation covered by Medicare?

When the clinician’s professional assessment finds a significant improvement, decline or change in the patient’s condition or function that the plan of care did not anticipate, and the documentation supports the need for further tests and measurements.⁠^2,7 The manual names three indications: new clinical findings, a significant change in condition, and failure to respond to the interventions in the plan.⁠²

A re-evaluation is not a routine, recurring service. Continuous assessment of progress is part of ongoing treatment and is not payable as a re-evaluation, and routine weekly assessments of expected progress are not payable as re-evaluations either.⁠^2,7 The manual adds that a re-evaluation should not be routinely required before every progress report.⁠¹

It may be appropriate just before a planned discharge, to decide whether goals were met or to inform the physician or the setting that continues the care.⁠² Re-evaluations are usually narrower than the initial evaluation, focused on the current treatment, but they require the same professional skills, and the decision to provide one is the clinician’s.⁠^2,7

What is the difference between a progress report and a re-evaluation?

A progress report is a required, periodic account of progress toward the current goals; a re-evaluation is a separately payable service that gathers new objective information when the condition changes in a way the plan did not anticipate.⁠^1,7 The manual says a progress report justifies medical necessity, while a re-evaluation provides information not found in other documentation.⁠^1,7

How do plan of care certification and recertification timelines work?

The plan is established before treatment begins, a physician or nonphysician practitioner certifies it within 30 days of the first treatment, the certification lasts for the plan’s duration or 90 calendar days, whichever is less, and recertification follows at least every 90 days.⁠^3,5,8 The plan must state the type, amount, frequency and duration of the therapy, the diagnosis and the anticipated goals.⁠⁸

• Initial certification. As soon as possible, which the manual defines as when the plan is obtained or within 30 days of the initial therapy treatment; the initial treatment includes the evaluation that produced the plan.⁠³
• Length. A physician or nonphysician practitioner may certify any duration up to a maximum of 90 calendar days, and the certification interval is not the same as a progress report period.⁠^3,7
• Recertification. At least every 90 days, or sooner when a significant modification becomes evident; the record must show the continuing need for therapy.⁠^3,5
• Significant change. A change in long-term goals, such as treating a new condition, is significant, and the revised plan is certified within 30 days of the first treatment under it.⁠³
• Delay. A late certification is accepted with a reason for the delay, and no justification is needed for 30 days after it was due.⁠³
• Written order or referral. When a therapist establishes the plan, a written order or referral is in the record and the therapist documents delivering the plan to the physician or nonphysician practitioner within 30 days of the initial evaluation, the certification need not be signed by one who knows the case.⁠⁵

The therapy documentation audit guide covers how missing certifications show up in medical review.

What happens when the certification is late or never signed?

A late certification is accepted when the physician or nonphysician practitioner certifies later with a reason for the delay, for example a plan the physician did not sign or an original that was lost.⁠³ A payment denial for a missing certification is a technical denial, overturned if an appropriate certification is later produced.⁠³ When the therapist’s own office is the supplier, a technical denial for a missing certification leaves the patient liable, so the manual recommends telling the patient about the certification requirement and what its absence means.⁠³

What are the 2026 KX modifier thresholds for PT?

For calendar year 2026, the KX modifier threshold is $2,480 for physical therapy and speech-language pathology services combined, and a separate $2,480 for occupational therapy.⁠⁴ Claims above the threshold without the KX modifier are denied; the modifier confirms that the services are medically necessary as justified by documentation in the record.⁠^4,6

The threshold is indexed each year by the Medicare Economic Index.⁠⁴ A separate targeted medical review threshold sits at $3,000 for PT and SLP services and $3,000 for OT services each year until 2028, when it is also indexed; CMS says not all claims above it are reviewed.⁠⁴

Who pays when a claim is denied for a missing KX modifier?

The therapist or therapy provider, unless a valid Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) was issued to transfer liability to the patient.⁠⁶ The therapy modifiers guide explains how the KX modifier sits on the claim beside the discipline modifiers.

What should a PT document to show medical necessity?

Objective evidence that skilled therapy is needed: for rehabilitation, that the condition can improve or is improving and that the improvement is attainable in a reasonable, generally predictable time; for maintenance, that the therapist’s skills are needed because the program cannot be safely carried out by the patient, a caregiver or unskilled personnel.⁠¹ Coverage does not turn on the potential for improvement but on the need for skilled care.⁠⁶

Improvement is shown by successive objective measurements whenever possible.⁠⁶ The manual defines objective evidence as standardized patient assessment instruments, outcome measurement tools or measurable assessments of functional outcome, and recommends using them at the start of treatment, during it and after it.⁠¹ A treatment note is also required for every treatment day and every therapy service, so the progress report summarizes what the daily notes already show.⁠⁶

How should goals be numbered across progress reports?

Consistently: the manual suggests numbering long-term goals 1, 2, 3 and lettering their short-term goals 1.A, 1.B, keeping each goal’s identifier unchanged for the episode and giving new goals new identifiers.⁠¹ The progress report may add, change or delete short-term goals, since only long-term goals are required in the plan.⁠¹

How do outcome measures support PT progress reports?

They turn progress into successive objective measurements, which is how the manual says improvement should be shown whenever possible.⁠⁶ Medicare recommends, but does not require, one of four instruments at evaluation: ASHA’s National Outcomes Measurement System, FOTO’s Patient Inquiry, the Activity Measure for Post Acute Care (AM-PAC), or OPTIMAL through the American Physical Therapy Association.⁠²

The gait speed and balance measures references in the clinical resources library cover two of the most used measures in detail.

For adults with neurologic conditions, a clinical practice guideline from the Academy of Neurologic Physical Therapy recommends a core set: the Berg Balance Scale, the Functional Gait Assessment, the Activities-specific Balance Confidence Scale, the 10 meter Walk Test, the 6-Minute Walk Test and the 5 Times Sit-to-Stand.⁠⁹ It recommends giving each measure under the same test conditions at admission, at discharge and, when feasible, in between, and documenting patient goals at least at admission and discharge.⁠⁹

How often should outcome measures be repeated in an episode?

At admission and discharge at a minimum, and between them when feasible, under the same conditions each time.⁠⁹ For Medicare, repeating a measure at each progress report gives the successive objective measurements the manual asks for, while a measure given as part of ongoing assessment is not by itself a payable re-evaluation.⁠^2,6 The guideline also asks therapists to discuss the results with patients and decide with them how the results shape the plan.⁠⁹

How do certification, progress reports and KX connect?

It runs on three clocks at once: progress reports every 10 treatment days, certification intervals of up to 90 calendar days, and the calendar-year KX threshold.⁠^1,3,4 The manual stresses that recertification dates do not affect progress report dates.⁠¹

The figures in the example are inputs chosen to show the rules, not benchmarks for a knee replacement episode.

How do other payers and settings differ from Medicare Part B?

The rules on this page are Medicare Part B’s outpatient therapy rules; other payers set their own in their policies, and the payer’s own policy governs each claim. The Medicare manual itself notes that some state regulations require re-evaluation at specific times, and that for Medicare payment such re-evaluations must also meet Medicare’s coverage criteria.⁠⁷

The manual encourages, without requiring, progress reports more often than the minimum, so that anyone reviewing the record can easily see that the services were appropriate, covered and payable.⁠¹ The eight-minute rule guide covers how timed minutes in each treatment note become billed units.

Does the progress report rule apply to OT and speech therapy too?

Yes. The progress report section applies to PT, OT and SLP alike, and states that a referring or supervising physician or nonphysician practitioner need not sign progress reports written by a PT, OT or SLP.⁠¹ The KX threshold differs by discipline only in grouping: PT and SLP share one amount, OT has its own.⁠⁴

Sources

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.3.D, Progress Report). Checked October 30, 2026.
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   “The progress report provides justification for the medical necessity of treatment.”; “Functional documentation is required as part of the progress report at the end of each progress reporting period.”; “information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant.”; “October 5 ends the reporting period and the next treatment on Monday, October 8 begins the next reporting period.”; “The treatment note shall explain the reason for the clinician’s missed active participation.”; “The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented.”; “If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible.”; “Clinicians are encouraged, but not required to write progress reports more frequently than the minimum required in order to allow anyone who reviews the records to easily determine that the services provided are appropriate, covered and payable.”; “Although the progress report written by a therapist does not require a physician/NPP signature when written as a stand-alone document, the revised plan of care accompanied by the progress report shall be re-certified by a physician/NPP.”; “Date of the beginning and end of the reporting period that this report refers to;”; “Date that the report was written (not required to be within the reporting period);”; “Signature, and professional identification, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was dictated;”; “Objective reports of the patient’s subjective statements, if they are relevant.”; “Note that assistants may not make clinical judgments about why progress was or was not made, but may report the progress objectively.”; “Preferably, the long term goals may be numbered (1, 2, 3,) and the short term goals that relate to the long term goals may be numbered and lettered 1.A, 1.B, etc.”; “The identifier of a goal on the plan of care may not be changed during the episode of care to which the plan refers.”; “shall add new goals with new identifiers or letters.”; “Since only long term goals are required in the plan of care, the progress report may be used to add, change or delete short term goals.”; “It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT, OT or SLP.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “For example, for a patient evaluated on Monday, October 1 and being treated five times a week, on weekdays:”; “If the clinician does not choose to write a report for the next week, the next report is required to cover October 8 through October 19, which would be 10 treatment days.”; “PTAs or OTAs may write elements of the progress report dated between clinician reports.”; “The clinician must write a progress report during each progress report period regardless of whether the assistant writes other reports.”; “The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge.”; “Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.”; “Care must be taken to assure that documentation justifies the necessity of the services provided during the reporting period, particularly when reports are written at the minimum frequency.”; “In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.”; “In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.”; “The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment.”; “It should be emphasized that the dates for recertification of plans of care do not affect the dates for required progress reports.”; “Days on which a patient does not encounter qualified professional or qualified personnel for treatment, evaluation or re-evaluation do not count as treatment days.”; “If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period.”; “If each element required in a progress report is included in the treatment notes at least once during the progress report period, then a separate progress report is not required.”; “The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment.”; “Reports written by assistants are not complete progress reports.”; “Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur.”; ““increasing strength” is not an objective measurement, but “patient ambulates 15 feet with maximum assistance” is objective.”; “Assessment of improvement, extent of progress (or lack thereof) toward each goal;”; “Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report; and”; “Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.”; “A re-evaluation should not be required before every progress report routinely, but may be appropriate when assessment suggests changes not anticipated in the original plan of care.”; “Objective evidence consists of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome.”; “Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.”; “Such tools are not required”.
2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.3.C, Evaluation/Re-evaluation and Plan of Care). Checked October 30, 2026.
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   “Results of one of the following four measurement instruments are recommended, but not required:”; “National Outcomes Measurement System (NOMS)”; “Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)”; “Activity Measure – Post Acute Care (AM-PAC)”; “OPTIMAL by Cedaron through the American Physical Therapy Association”; “Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations.”; “Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.”; “A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.”; “Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the plan of care.”; “A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.”; “Reevaluation requires the same professional skills as evaluation.”.
3. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.1.2, Plans of Care, and §220.1.3, Certification and Recertification). Checked October 30, 2026.
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   “Physician/NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan.”; “A change in long-term goals, (for example if a new condition was to be treated) would be a significant change.”; “The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements noted above in §220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less.”; ““As soon as possible” means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment.”; “The initial treatment includes the evaluation that resulted in the plan.”; “Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.”; “A physician/NPP may certify or recertify a plan for whatever duration of treatment the physician/NPP determines is appropriate, up to a maximum of 90 calendar days.”; “Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay.”; “Certifications are acceptable without justification for 30 days after they are due.”; “Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay. For example, a certification may be delayed because the physician did not sign it, or the original was lost.”; “Denial for payment that is based on absence of certification is a technical denial, which means a statutory requirement has not been met.”; “If an appropriate certification is later produced, the denial shall be overturned.”; “However, if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability.”; “it is recommended that the patient be made aware of the need for certification and the consequences of its absence.”.
4. Centers for Medicare & Medicaid Services. Therapy Services (CMS webpage; the Bipartisan Budget Act of 2018 section, last revised February 2026). Checked October 30, 2026.
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   “there is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI).”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied.”; “Through section 50202 of the BBA of 2018, the law preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.”; “For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and $2,480 for OT services.”; “For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.”; “The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were.”.
5. Electronic Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (paragraph (c), as in force October 1, 2026). Checked October 30, 2026.
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   “The initial certification must be obtained as soon as possible after the plan is established.”; “Recertification is required at least every 90 days.”; “When it is recertified, the plan or other documentation in the patient’s record must indicate the continuing need for physical therapy, occupational therapy or speech-language pathology services.”; “and there is a written order or referral from the individual’s physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS) in the patient’s record and the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case.”.
6. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.2, Reasonable and Necessary Outpatient Rehabilitation Therapy Services, and §220.3, Documentation Requirements for Therapy Services). Checked October 30, 2026.
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   “Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”; “Improvement is evidenced by successive objective measurements whenever possible”; “Under section §1833(g)(8), the therapist or therapy provider is financially liable for the cost of therapy services provided to a beneficiary above the threshold amount when Medicare denies payment for failure to use the −KX modifier to indicate that the services are medically necessary as justified by documentation in the medical record.”; “In order for the therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid ABN, Form CMS-R-131.”; “Documentation is required for every treatment day, and every therapy service.”.
7. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220, part A, Definitions). Checked October 30, 2026.
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   “RE-EVALUATION provides additional objective information not included in other documentation.”; “Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care.”; “Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines.”; “The decision to provide a reevaluation shall be made by a clinician.”; “INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individual’s needs.”; “The certification interval is not the same as a Progress Report period.”; “Functional reporting requirements are no longer applicable for claims for dates of service on and after January 1, 2019.”; “Routine weekly assessments of expected progression in accordance with the plan are not payable as re-evaluations.”; “ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.”.
8. Electronic Code of Federal Regulations. 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (as in force October 1, 2026). Checked October 30, 2026.
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   “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”; “The plan is established before treatment is begun by one of the following:”; “Any changes in the plan— (1) Are made in writing and signed by one of the following:”; “The changes are incorporated in the plan immediately.”.
9. Moore JL, Potter K, Blankshain K, Kaplan SL, O’Dwyer LC, Sullivan JE. A core set of outcome measures for adults with neurologic conditions undergoing rehabilitation: a clinical practice guideline (J Neurol Phys Ther 2018;42(3):174-220; Academy of Neurologic Physical Therapy of the APTA; DOI 10.1097/NPT.0000000000000229; PMID 29901487; PMC6023606; full text as shown on PubMed Central). Checked October 30, 2026.
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   “Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence.”; “Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance.”; “Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers.”; “The BBS should be administered under the same test conditions using the protocol recommended by the CPG Knowledge Translation (KT) Committee at admission, and discharge, and when feasible, between these periods”; “Patient goals should be documented at least 2 times, at admission and discharge, and, when feasible, between these testing periods”; “Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care.”; “The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT).”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is a clinical documentation reference for licensed clinicians, not legal, compliance or billing advice. Medicare’s manuals, the clinic’s Medicare contractor and each payer’s own policy govern any claim, and the worked timeline is a hypothetical example, not a real patient.