I receive many questions regarding is assessment time billable time for outpatient therapy services and if yes, how do I account for that time in my billing. In this article, I will provide the answers to 4 of the more common questions I receive regarding accounting for assessment time.
Is assessment time billable time?
When can assessment time begin?
Can you give me an example of assessment time and how it can be included within a CPT code?
Can you give a second example on how taking vital signs can be included in the assessment time of a CPT code?
I hope you found this article to be informative and that you now have a better understanding of assessment time and how that is skilled billable time. Thank you for being a Gold Member!
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I am wondering we practice in WI can we have more than 1 fee schedule ?
Not a question I can answer in this format.
Would cases management time with an MD/DON in the presence of the patient (like an AL community) count towards assessment or treatment or is non-billable time?
My opinion only, no.
My Billing manager took your course and stated that she learned that Occupational Therapists can charge for Therapeutic Exercises on day of initial evaluation if the Therapist instructs the patient on HEP for more than 8 minutes even if the patient does not perform one actual exercise (Instruction/education on written HEP only).
Is this correct? I would like to clarify this with the billing Dept. as soon as possible. Thank you for your clarification in advance. We are a Physician owned Outpatient clinic, all payor sources including Medicare, work comp and private Ins.
Abel Cavazos OTR,CHT
If teaching a patient exercises to do at home that would fall under CPT code 97110, you could bill 97110 assuming you provided the service for enough minutes.
Great article. Do you have anything on documentation time? Documentation at point of service specifically. Thanks Rick!
Thank you. I do not have an article specifically on when, where and how to document.
Would reading and interpreting an MRI report that a patient brings in to therapy be considered billable time during a follow up visit (not an evaluation visit)?
Hasn’t the MRI been interpreted already by the radiologist? Secondly, not a question I can answer in this forum.