Please note that this article contains information that is only relevant to American clinics. 

 

Do you ever find yourself wondering whether or not you need to document the time for your Medicare Part B patients? Perhaps it’s unclear if you need to record the length of the entire appointment, or if you just need to keep track of the time for an individual CPT code. Fortunately the folks from Gawenda Seminars and Consulting have written an article addressing this issue.

 

The article states that “For outpatient therapy services provided under Medicare Part B, the required elements for documentation of time are: total ‘timed code’ treatment in minutes, and total ‘treatment time’ in minutes.” Let’s distinguish the difference between ‘timed’ and ‘untimed’ CPT codes.

 

Click here to read our articles about timing therapy notes for Medicare patients.

 

Certain CPT codes are considered ‘timed’. This means that a unit of treatment for a code that is considered ‘timed’ will require that you log how much time was spent performing that specific treatment. A good example of which is the manual therapy CPT code (97140), which accounts for 15 minutes of treatment. So, if you only spent 15 minutes providing manual therapy, you can only bill 1 unit of CPT 97140, and you will need record the 15 minutes spent performing that treatment–this is your ‘total timed minutes’. 

 

Other CPT codes are considered ‘untimed’. Performing treatment based on an ‘untimed’ CPT code means that you won’t need to record the specific amount of time spent performing the treatment. Regardless of whether you spend 10, 20, or 30 minutes assisting a patient with mechanical traction (CPT 97012), you can only bill 1 unit. However, you still must record the amount of time in your ‘total treatment time’.

 

To further illustrate the difference between ‘timed’ and ‘untimed’ treatment codes, let’s create an example: A patient visits your facility for their regularly scheduled therapy session.

 

Let’s say that you provided 30 minutes of manual therapy–a timed CPT code. When you’re finished with the manual therapy, you set them up for 20 minutes of mechanical traction–an untimed code. Now let’s review the total amount of time that ought to be recorded in your documentation:

 

– Total ‘timed’ treatment: 30 minutes

 

– Total treatment time: 50 minutes

 

Because mechanical traction is an ‘untimed’ treatment code, it is the only counted in the total treatment time. Thus, only one unit may be billed. On the other hand, manual therapy is a ‘timed’ treatment code, and you may bill 2 units (15 mins each). And this should shed some light on how to document time for Medicare patients.

 

We hope you found article helpful. For more Medicare related information like this, be sure to head over to Gawenda Seminars and Consulting and learn more about how to become a Gold Member.

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