Eli's Rehab Report

Published on Mon Aug 27, 2007 PDF

Question: I recently heard that I don't have to break down the number of minutes I spend with a patient in each modality. Is that a new rule by Medicare? Every course I've taken in the past says I must break down every minute I spend with the patient.

Indiana Subscriber

Answer: You do not have to break down the number of minutes for each modality in your documentation, and CMS actually never required this. In the past, some specific Medicare contractors were requiring it, but CMS confirmed in a March 13, 2006, transmittal that individual contractors cannot require that you document the minutes you spend on each CPT code.

You can find the statement now in the Medicare Benefit Policy Manual (www.cms.hhs.gov/Manuals). Click on "Internet-Only Manuals" and then the link to "Pub 100-2." Click on "Chapter 15" and see the references to "treatment note" under section 220.3 E.

What you do have to document in terms of time are the minutes you spend providing time-based interventions and the total treatment time -- that is, the time-based and the un-timed CPT codes.

Best bet: Keep in mind that for some procedures, you'll document the time anyway. For example, a therapist would want to note that she applied e-stim for 15 minutes, but she doesn't have to document that she spent 17 minutes doing exercise, 15 minutes doing manual therapy, 13 minutes of doing self-care, etc. Just make sure your timed minutes and total treatment time correlate to the number of units you bill.

How to do it: Suppose you spend 35 minutes on timed procedures and 20 minutes on an untimed or service-based procedure. Document the timed procedures as 35 minutes and the total treatment time as 55 minutes and bill three units: two units of time-based procedures and one unit for the untimed procedure.

-- Reader Questions were answered by Rick Gawenda, PT, director of physical medicine and rehabilitation at Detroit Receiving Hospital and owner of Gawenda Seminars.