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:
The content here is for members only log in here or sign up.
All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.
This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.
Should non-billable things/time the patient is in the clinic be included in the total treatment time? for example the patient warms up on a piece of equipment prior to their appointment, or the patient is assisted by an aide with an exercise.
Please read Section 220.3E where CMS discusses unbilled services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
CMS states: 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.