How to Document Time in the Medical Record

May 27, 2019
Rick Gawenda

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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