RE: Documentation of timed and untimed code minutes spent

April 20, 2011

You are documenting way too specifically as it is now. I have pasted the

documentation of time requirements for Medicare outpatient therapy services.

Total timed code treatment minutes and total treatment time in minutes. Total

treatment time includes the minutes for timed code treatment and untimed code

treatment. Total treatment time does not include time for services that are not

billable (e.g., rest periods). For Medicare purposes, it is not required that

unbilled services that are not part of the total treatment minutes be recorded,

although they may be included voluntarily to provide an accurate description of

the treatment, show consistency with the plan, or comply with state or local

policies. The amount of time for each specific intervention/modality provided to

the patient may also be recorded voluntarily, but contractors shall not require

it, as it is indicated in the billing. The billing and the total timed code

treatment minutes must be consistent.

Here is the link. Read Section 220.3E.

http://www.cms.gov/manuals/Downloads/bp102c15.pdf

Rick Gawenda, PT

President

Gawenda Seminars & Consulting, Inc.

www.gawendaseminars.com

Upcoming audio conference at

https://www.showmyevent.com/events/viewEventDetails.aspx?EventID=1516

Subject: Documentation of timed and untimed code minutes spent

To: PTManager

Cc: " Sachse "

Date: Wednesday, April 20, 2011, 5:03 PM

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Currently we are documenting minutes spent for each timed and untimed CPT

code. We have not been formally audited by CMS but we are trying to determine

if we need to be even more specific. Instead of stating we performed manual

therapy for 15 minutes, do we need to document that we performed technique 1 for

5 minutes, technique 2 for 10 minutes, etc?

Obviously documenting time for each specific treatment modality is time

consuming and would like to avoid this unless we truly have to. Any insight you

can provide would be helpful.

Jon Weiss, PT, LAT

Information Services - Bellin Health

Green Bay, Wisconsin

Phone: x2612

Fax:

April 21, 2011

Hi Jon,

Just to clarify that we are talking about Medicare policy here. What your

clinic does for the rest of insurances is up to each individual insurance,

any accrediting body (if used) and your facility rules. Many clinics use

the Medicare policy rules across the board but just to be sure and for the

purposes of discussion, we are just talking about Medicare clients and

charting for them. You are also talking about PART B (Outpatient) PT

correct? Part A services follow a different policy.

So for Part B Medicare services, the Medicare Benefits Policy Manual

requires the following:

1) Total treatment time (some facilities and accrediting bodies

interpret this as time in and time out but the policy only requires total

treatment time)

2) Total TIMED code time (this is a very important one to have)

3) Time for each procedure (so yes you have to list a time for each

treatment you do)

Why is this the policy? You have to think of it in terms of a non-PT

looking at the chart reviewing it for whether or not you have followed

Medicare policy. These three times, when matched with billing, will allow a

reviewer to determine if the 8 minute rule has been followed and if billing

matches the documentation. Not having these times is grounds for denial of

that claim.

We actually developed a template in our charting system to remind us what to

list and I think most updated systems do the same. Hope that answers your

question.

M. Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, Idaho

thowell@...

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From: PTManager [mailto:PTManager ] On Behalf

Of Jon Weiss

Sent: Wednesday, April 20, 2011 3:03 PM

To: PTManager

Cc: Sachse

Subject: Documentation of timed and untimed code minutes spent

Currently we are documenting minutes spent for each timed and untimed CPT

code. We have not been formally audited by CMS but we are trying to

determine if we need to be even more specific. Instead of stating we

performed manual therapy for 15 minutes, do we need to document that we

performed technique 1 for 5 minutes, technique 2 for 10 minutes, etc?

Obviously documenting time for each specific treatment modality is time

consuming and would like to avoid this unless we truly have to. Any insight

you can provide would be helpful.

Jon Weiss, PT, LAT

Information Services - Bellin Health

Green Bay, Wisconsin

Phone: x2612

Fax:

April 21, 2011

Absolutely correct From Rick and I apologize that I forgot that the time of each

treatment is voluntary. As a reviewer myself I can tell you that having times

next to each treatment is a big help in understanding what was actually done so

I always recommend it. The reality is that it is up to you.

M. Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, Idaho

thowell@...

This email and any files transmitted with it may contain PRIVILEGED or

CONFIDENTIAL information and may be read or used only by the intended recipient.

If you are not the intended recipient of the email or any of its attachments,

please be advised that you have received this email in error and that any use,

dissemination, distribution, forwarding, printing or copying of this email or

any attached files is strictly prohibited. If you have received this email in

error, please immediately purge it and all attachments and notify the sender by

reply email.

From: PTManager [mailto:PTManager ] On Behalf Of

Rick Gawenda

Sent: Wednesday, April 20, 2011 10:39 PM

To: PTManager

Subject: Re: Documentation of timed and untimed code minutes spent