Documentation of Time for Medicare Therapy Patients

December 4, 2017
Rick Gawenda

Lately, I have been receiving questions regarding what must a therapist or 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. The answer below applies to traditional Medicare Part B only and not to Medicare Advantage plans, Medicaid, and private insurance carriers.

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

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