Progress Reports: Billing for Your Time

April 11, 2016
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Rick Gawenda
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In last weeks article, “When to Bill For a Reevaluation”, I discussed when it would be appropriate to perform and bill for a reevaluation. In this weeks article, I want to teach you how to account for your time when you are gathering subjective comments from a patient or their caregiver as well as the time you spend gathering objective data to write a Progress Report that may be required by the insurance carrier (i.e. Medicare, Workers Compensation) or due to the patient having a return visit to their physician.

To begin, there is no CPT code that exists to specifically be able to bill for the purpose of gathering the data and the time associated with writing the Progress Report. There is no Progress Report or assessment CPT code. So then how does a therapist account for their time associated with all the components of the Progress Report?

The time a therapist spends with a patient or a patient’s caregiver gathering the subjective comments as well as the time associated with gathering the objective data such as range of motion measurements, manual muscle testing, edema measurements, posture assessment, gait assessment, etc., is added on to the CPT code(s) that was billed that date of service for that visit.

For example, during a follow-up treatment visit, the therapist spent

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  1. Good series, thanks for the clarification. Do you recommend documenting specifically that reassessment minutes are being added to a specific CPT category, or is it assumed that they are being distributed across other treatment codes for that day?

    1. Thanks for the positive feedback. How you document the minutes, I leave that up to the individual therapist.

    1. That CPT code is not for taking ROM and doing MMT testing. Watch for a future article discussing CPT code 97750.

  2. Do you recommend the same method to bill for time on a regular visit (not progress report) for the additional time spent with patient and caregiver, say at the end of the session discussing ADLs, etc?

    1. Based on what you are teaching them and/or instructing them to do, that time would be counted under the appropriate CPT code.

  3. Rick,
    Thank you for your informaton. If you put in the explanation of the CPT code 97110 -Patient education and objective measurements taken, is this appropriate or can that be a red flag for the insurance companies? And can this be done on the prog note as well as a daily note? How often is it required that objective measurements be updated in a daily note between progress notes? Thanks you for your time.

  4. “During the same session, the therapist spent 10 minutes asking the patient about their pain, what they can now do since starting therapy, what still can’t they do or are still having difficulty doing, how they are sleeping at night, and taking range of motion measurements and performing manual muscle testing of the right shoulder. That 10 minutes would be considered skilled therapy and would be added on to the 30 minutes already provided for a total of 40 minutes of direct one-one patient contact time.” Three of our outpatient PT clinic locations recently completed a Phase 1 audit with Noridian and received several denials for counting time such as the “10 minutes” described in your example when determining the total treatment time.

      1. I understand. The comment from the Noridian claim reviewer was that “time spent on data gathering is not billable as 1:1 time with a patient”. I suppose I am mentioning this as an FYI. I have shared your example with our Noridian reviewer with a request for clarification and would be happy to post her reply here, if doing so would be helpful.

        1. I should clarify my previous comment. The Noridian reviewer stated that “time spent on data gathering is not billable as 1:1 time with a patient when calculating total treatment time for the purpose of determining the number of billable treatment units”.

          1. You may want to retain a consultant to help you in this area and teach the Noridian reviewer what is included in the payment of a CPT code. There is a pre-service time, intra-service time and post-service time for a CPT code. The intra-service time includes the services provided while you are with the patient and/or family. This includes the time in which the physical therapist obtains the history, performs an examination using standardized tests and measures, develops a plan of care, and counsel the patient.

        2. You may want to retain a consultant to help you in this area and teach the Noridian reviewer what is included in the payment of a CPT code. There is a pre-service time, intra-service time and post-service time for a CPT code. The intra-service time includes the services provided while you are with the patient and/or family. This includes the time in which the physical therapist obtains the history, performs an examination using standardized tests and measures, develops a plan of care, and counsel the patient.