Documentation of Time for Medicare Therapy Patients
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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Please clarify, is time spent on a non-billable treatment such as ice or Laser included in the total treatment time?
Please read the reference provided in the article. It will tell you the following: For Medicare purposes, it is not required that unbilled services that are not part of the total treatment minutes be recorded, although they may be included voluntarily to provide an accurate description of the treatment, show consistency with the plan, or comply with state or local policies.
You state that “teaching/education and/or assessing the patient would not be included in the time documented for total timed minutes or total treatment time.”
I have always been under the impression that patient education and assessment time was billable time, so why would this NOT be included?
Please re-read the article. What it states is the following: time where the patient is resting and the therapist is not providing any skilled interventions, teaching/education and/or assessing the patient would not be included in the time documented for total timed minutes or total treatment time.
How does the time from an evaluation factor into minutes? It is an un-timed code and not “treatment”. Are the minutes counted in the “total”, or just left out completely?
ie: Eval x 30 minutes, 97110 x 30 minutes. Total timed minutes = 30. Total treatment time = 30 or 60 minutes???
They would be part of the total treatment time.
Is it required to document the time spent on each modality? The modality codes are time based codes. You reference as it is indicated in the billing. In the Medicare claims manual See Pub. 100-04, chapter 5, section 20.2. We are looking for clarification if each modality time needs to be documented. Thank you.
Please read the article: http://gawendaseminars.com/2017/current-news-posts/documentation-of-time-for-medicare-therapy-patients/
At the end of the article, I provide the reference to read and you will find your answer.
In a previous post (10/16/17) on documentation time, it was stated that therapists need to document the time they are finished with their documentation. If a therapist doesn’t document immediately, would the time be the time the session ended or the time that he/she truly finished the documentation?
The article on 10/16/17 is discussing documenting time on physician orders and time that you write the note that is a CMS requirement for some practice settings. The time you would document for the note would be the time you are writing the note.
http://gawendaseminars.com/2017/current-news-posts/do-therapy-orders-notes-need-to-be-timed-for-medicare-patients/
To clarify, is Mechanical Traction an untimed code? I was under the impression that it was timed (based on time spent setting up, not based on patient time spent on traction).
Mechanical traction is an untimed CPT code.
I am trying to locate where it states that for modalities, set up and take down are included in treatment time. 1) Is this an accurate statement 2)If so, is that only seen in a manual such as CPT assistant? As an FYI, I am particularly looking at CPT G0283. Thanks. (Matt Mesibov)
Supervised modalities are untimed and only billed as 1 unit so time really does not matter. This would include G0283 since it is an untimed service.