Documentation Requirements for Therapy Services

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 10th, 2015

Documentation Requirements for Therapy Services, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units for the total therapy minutes provided.

Example 1

24 minutes of neuromuscular reeducation, code 97112,

23 minutes of therapeutic exercise, code 97110,

Total timed code treatment time was 47 minutes.

 

See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes. Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.

 

Example 2

20 minutes of neuromuscular reeducation (97112)

20 minutes therapeutic exercise (97110),

40 Total timed code minutes.

Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.

Example 3

33 minutes of therapeutic exercise (97110),

7minutes of manual therapy (97140),

40 Total timed minutes

Appropriate billing for 40 minutes is for 3 units.

Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

Example 4

18 minutes of therapeutic exercise (97110),

13 minutes of manual therapy (97140),

10 minutes of gait training (97116),

8 minutes of ultrasound (97035),

49 Total timed minutes

Appropriate billing is for 3 units. Bill the procedures you spent the most time providing.Bill 1 unit each of 97110, 97116, and 97140.

You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.

Example 5

7 minutes of neuromuscular re education (97112)

7 minutes therapeutic exercise (97110)

7 minutes manual therapy (97140)

21 Total timed minutes

Appropriate billing is for one unit. The qualified professional (See definition in Pub.100-02, chapter 15, section 220) shall select one appropriate CPT code (97112, 97110,97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.

NOTE:

The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15 minute timed codes includes all direct treatment time for the timed codes. Total treatment minutes--including minutes spent providing services represented by untimed codes—are also documented. For documentation in the medical record of the services provided see Pub. 100-02, chapter 15, section 220.3

 

References:

Documentation Requirements for Therapy Services. (2015, August 10). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/documentation-requirements-for-therapy-services-26634.html

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