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How to Document Time in the Medical Record

Lately, I have been receiving questions regarding what must a therapist or an assistant document in regards to time for patients receiving outpatient therapy services under Medicare Part B. Does the Medicare program require time in and time out? Does the Medicare program require we document the minutes spent on each individual CPT code. In this article, I will answer what the Medicare program does and does not require in terms of documentation of time for each therapy visit as well as Medicare Advantage plans, Medicaid, private/commercial insurance carriers and workers compensation carriers.

For outpatient therapy services provided under Medicare Part B, the required elements for documentation of time are:

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Outpatient Therapy Common CERT Errors

The Centers for Medicare and Medicaid Services (CMS) has released a new booklet where they describe common outpatient rehabilitation therapy services Comprehensive Error Rate Testing (CERT) Program errors, how the CMS calculates improper payment rates, the necessary documentation to support billed Medicare claims, and managing potential overpayments. Some of the more common CERT errors include:

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UnitedHealthcare Community Plan Therapy Changes

UnitedHealthcare (UHC) Community Plan will begin Site of Care Medical Necessity Reviews and are also revising their prior authorization requirements for occupational, physical and speech therapy services. Beginning with dates of service on and after

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Recovery Audit Program and Therapy Services

The Medicare Fee-For-Service Recovery Audit Program was initiated in 2009 to reduce improper Medicare payments to suppliers and providers enrolled in the Medicare program. Since its inception, the program has recouped more than $10 billion for the Medicare program. It should be to no ones surprise that therapy services have contributed to the more than $10 billion recouped.

Current approved topics pertaining to therapy include:

To access the complete list of approved topics, click HERE.

Proposed topics pertaining to therapy include:

To access the complete list of proposed topics, click HERE.

I hope you found this article helpful.

Billing an Evaluation and CPT Code 97750 on the Same Day

A question I often receive is can I bill and be paid for an evaluation or reevaluation (CPT codes 97161-97168) and a physical performance test and measurement (CPT code 97750) when provided on the same date of service by the same discipline? To obtain the answer, we must refer to the

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