Eli's Rehab Report

Published on Wed Sep 08, 2010 PDF

Question: Our therapists aren't sure how to comply with timing documentation. Currently we document the start and finish times of all therapy sessions as well as the time that any part of the documentation was signed. Is that the correct way to document our time? Should we also state the duration of each therapeutic procedure? If so, must we break the visit down into specific units of time?

-- Minnesota subscriber

Answer: No, the Centers for Medicare & Medicaid Services doesn't require that you document the start and finish times for your therapy sessions -- and hasn't since 2006.

Do this: To comply with timing documentation, you should document the total time you provided therapeutic services rather than logging when you started and started. The total time will be the summation of time and untimed CPT code minutes, according CMS Pub 100-02, Chapter 15, Section 220.3 E.

In addition to the total time of treatment, you should also document the date of treatment, the specific intervention or modality you provided and billed for in language that can be compared with your claim, and any services you provided but didn't bill for. You should also supply the signature and professional ID for any professional who furnished or supervised the services and a list of each person who contributed to the treatment.

Resource: For full details on how to document your services, access the CMS manual at www.cms.gov/manuals/Downloads/bp102c15.pdf.