Eli's Rehab Report

READER QUESTIONS:

Tell Therapist 'Document Everything'

Question: My therapist spent only three minutes applying an ultrasound to a patient (97035). Because this isn't a reportable service, does it still mean that he should document those three minutes?


Michigan Subscriber


Answer: Absolutely. Documentation of services provided is more than just a means to support coding and billing. Also, even though you may not be able to bill one unit of 97035 (Application of a modality to one or more areas; ultrasound, each 15 minutes), your therapist must document the time he spent with the patient.
 
Medicare says, "A therapist or therapy assistant should record the total treatment time (or the actual beginning or ending time of treatment) for services described by timed codes, untimed codes, and unattended (billed and unbilled) activities."

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