Eli's Rehab Report

Distinguish between required and voluntary reporting for timed codes.

Question: Currently, we document how many minutes we perform each therapy modality, such as 15 minutes spent performing manual therapy. Should we more specific? For instance, does the Centers for Medicare & Medicaid Services prefer that we document we spent five minutes on one technique and 10 minutes on another?

Answer: No, and your documentation is already more specific than it needs to be, says Rick Gawenda, president of Gawenda Seminars & Consulting.

Medicare requires that you report the total treatment minutes for the timed code and then the total minutes you provided treatment, which includes both the timed and untimed codes. You shouldn't include minutes for any non-billable time, such as rest periods.

For instance, any time spent in evaluation shouldn't be billed as treatment time. However, those minutes are included in the total treatment minutes.

Important: Though Medicare doesn't require you to include any unbilled services in your total treatment time, you can choose to report them to give a more accurate description of the treatment you provided, show consistency with the plan of care, or comply with state or local policies, CMS states.

The bottom line: You can note the amount of time for each specific intervention or modality you provide -- but that information is not required.

Resource: For more information about timed versus untimed codes, check Chapter 15 of the Medicare Benefit Policy Manual at www.cms.gov/manuals/Downloads/bp102c15.pdf