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Good Afternoon,
We're working on improving our EMR documentation and I need some guidance on documentation for time-based PT codes. For example, our providers perform manual therapy (97140) and may work several areas. From a compliance standpoint, do we need to document the time spent on each area, or would documenting the total time spent be sufficient? We also do active care with the patient after to make sure they know their stretches, are performing them properly, etc. Do we also need to document "Stretch A 5 minutes," "Exercise B 7 minutes," etc, or is it sufficient to list the exercises/stretches and the total time spent?
Thanks for your help!
Kimberly Shaw
We're working on improving our EMR documentation and I need some guidance on documentation for time-based PT codes. For example, our providers perform manual therapy (97140) and may work several areas. From a compliance standpoint, do we need to document the time spent on each area, or would documenting the total time spent be sufficient? We also do active care with the patient after to make sure they know their stretches, are performing them properly, etc. Do we also need to document "Stretch A 5 minutes," "Exercise B 7 minutes," etc, or is it sufficient to list the exercises/stretches and the total time spent?
Thanks for your help!
Kimberly Shaw