Medicare ADVISOR Q&A

Point-of-Service Documentation

Question: I work in the SNF for a large company with several facilities. Within the last year, the administration of the company has implemented the idea that the treating therapist is to do "point-of-service" documentation during the course of treating patients and bill for the time spent documenting.

Initially, we were a paper documentation we are doing computer documentation. Still, they expect me to bill that documentation time as "goal setting," and/or planning goals with the patient. I feel that it is unfair and unethical for me to be billing a patient while I type, (very slowly) and recap our entire week of therapy.

What does Medicare say about this for both Medicare Part A and Part B?

Answer: Medicare is very clear about this.  For Part A, the RAI (Resident Assessment Instrument) Manual, Chapter 3, page 3-187 states "The therapist's time spent on documentation or on initial evaluation may not be included."

For Part B, the IOM manual called Pub. 100-04, Medicare Claims Processing Manual, Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services, §20.3 - Determining what time counts towards 15-minute times codes - all claims, states: "Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not counted in determining the treatment time. In other words, the time counted as "intra-service care" begins when the therapist .. is directly working with the patient to deliver treatment services. The patient should already be in the treatment area (e.g. on the treatment table or mat or in the gym) and prepared to begin treatment.

The time counted is the time the patient is treated. ..The time the patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time."

While we have always advocated point-of-service documentation, this does not mean that all of the time spent documenting should be billed to the patient, especially when typing slowly!

During our seminars, we spend time on the subject of considering what should actually be called a skilled service. We have found that most of the time we, as therapists, do ourselves a disservice in counting what we do that is skilled. Certainly discussing progress with the patient, teaching the patient about the disease process, obtaining information from them that relates to our treatment that day, as well as performing observation and assessment is skilled therapy and should be included in the time billed. However, having the patient just sit there while you are reading what you are typing is not skilled treatment, no matter how you slice it.

If the patient is performing an activity, and you are supervising that activity, with direct patient observation, instruction, and assessment while, at the same time, you are documenting, then you are billing for the skilled treatment time, not the documentation time.

Disclaimer: The answers that we provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.

Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. Danna Mullins is an associate and lecturer with Encompass and practicing physical therapist. You may contact the authors through the Encompass website at or by phone at 954-720-4087.

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