Pauline Watts Danna Mullins
Question: Please differentiate billable and non-billable time/services. Does billable time vary according to setting, for example, inpatient rehabilitation vs. skilled nursing facility (SNF), and according to whether the patient is a Part A or Part B beneficiary? Currently, I am instructed to bill for time spent on evaluation (chart review, patient interview, staff interview, assessment, documentation, MDS, care plans, request for order); time spent writing weekly/progress note or time spent documenting attempt and patient refusal of treatment, discharge planning, home evaluation (from patient preparation through return to facility and documentation of results); and time spent on completing monthly billing forms 700 and 701 forms for Part B patients only.
Answer: Billing for service under Medicare has exactly the same requirements regardless of point of service. Most of the items you mentioned cannot be included in your billable time unless they meet certain criteria.
Evaluation: Under Part A in a SNF/SNU (skilled nursing unit), the time spent in the initial evaluation cannot be included in the minutes of therapy entered into section P1b of the MDS, but a portion of the re-evaluation can be included.
According to the Federal Register, July 30, 1999, J. Rehabilitation Therapy Services and PPS, page 41661:
"The time it takes to perform the formal initial evaluation and develop the treatment goals and the plan of treatment cannot be counted as minutes of therapy received by the beneficiary. However, a re-evaluationthat is, a hands-on examination of the beneficiary and not simply an update to the documentation and revision of the care planthat is performed once a therapy regimen is under way (for example, evaluating goal achievement as part of the therapy session) may be counted as minutes of therapy received."
With this example they are referring to only the hands-on time of a re-evaluation, not the documentation time for completion of a 701 or charting.
Under Part B, the evaluation is a billable service that is not a time-sensitive HCPCS code. Therefore, it has a fixed reimbursement value irrespective of the time spent in the performance of the evaluation. The HCPCS code for re-evaluation is also subject to the requirement that it needs to be a hands-on re-evaluation of the patient, not just a completion of form 701.
Therapy treatment outside of the building: This topic is addressed in the same section of the noted Federal Register:
"The therapy treatment may occur inside or outside the facility. This includes the time it takes for the therapist to take the beneficiary to his or her home for a visit before discharge as long as the therapist uses the time in the car to teach or discuss the beneficiary's treatment or treatment goals and for family conferences when the beneficiary is also present."
The time in family conference must be for discussion of treatment goals or to teach the family specific techniques or give instructions that constitute a skilled level of care, not just to obtain information.
Billable time: For Part A, time that can be included as minutes on the MDS is identified in the Federal Register as:
..."time starts when he begins the first treatment activity or task and ends when he finishes with the last apparatus and the treatment is ended."
This certainly does not appear to include care plan meetings, discussions with the physician and other staff, obtaining orders, discharge planning, documenting the patient's refusal of treatment, etc. It is considered fraudulent activity if you falsify section P1b of the MDS (the minutes of care provided during the assessment period), placing the beneficiary into a higher RUG-III than that for which services have been provided.
For Part B, the HCPCS codes for therapeutic procedures are time sensitive and are for direct (one-on-one) patient contact only. If you are including in the billing any non-direct patient time, you are billing incorrectly and it could be interpreted as Medicare fraud.
Health Care Financing Administration. (1999, July 30). Medicare program; prospective payment system and consolidated billing for skilled nursing facilities-update; final rule and notice. Federal Register, 64(146), 41643-41683.
Health Care Financing Administration. (2000, October). Outpatient physical therapy comprehensive outpatient rehabilitation facility and community mental health center manual. Washington, DC: Author.
If you have a question about Medicare reimbursement you would like the authors to address, send your question and contact information to Medicare Advisor, c/o Linda Jones, ADVANCE for PTs & PTAs, 2900 Horizon Dr., King of Prussia, PA 19406; fax (610) 278-1425; firstname.lastname@example.org.
Pauline Watts and Danna Mullins are the co-founders of Encompass Education, Inc., a rehabilitation education and consulting firm in Palm Harbor, FL. You may contact the authors at email@example.com