This is an opinion piece by a therapist at Fusion Web Clinic and should not be considered legal advice.
There's a lot of confusion surrounding when (or if) it is appropriate for a pediatric therapist to bill for time spent on documentation. Some therapists say it's never appropriate, and some don't think twice about documenting during treatment and billing for it.
According to APTA's Center for Integrity in Practice: "Documentation should be completed at the point of care or soon afterward," and a list of documentation tips from OT managers compiled by AOTA also contains a tip recommending point-of-care documentation.
But when it comes to billing for treatment, the RAI User's Manual says that only skilled therapy time is billable and "[t]he therapist’s time spent on documentation or on initial evaluation is not included."
Is there a way to do both?
Technically speaking, you usually can't bill just for documentation (there are exceptions, like CPT 96125, which includes time for analyzing data and writing a report). But what if you're billing for time spent providing a skilled service when you happened to be documenting simultaneously?
Let's start by asking what does "skilled therapy time" actually mean? According to the Centers for Medicare & Medicaid Services (CMS), it means that, among other things, "the services must be of a level of complexity and sophistication, or the condition of the resident must be of a nature that requires the judgment, knowledge, and skills of a therapist."
When I was starting out, based on my interpretation of those rules at the time, I thought that any sort of documentation was inappropriate. Instead I would wait until later in the day--or week--to document sessions.
This meant that I would often end up with a huge stack of notes (not always legible, unfortunately) that I would have to go through to complete my documentation. And if I couldn't read my notes, I had to think back and try to remember the visit, which wasn't always easy.
Jeremy Furniss, OTD, MS, OTR/L, BCG is the Director of Quality at AOTA. It's his job to "bring best practice into current practice". AOTA doesn't have an official position on point-of-care documentation, but Furniss says that whether or not you can ethically bill for time spent documenting depends on what's going on with the service and what you're billing.
“You should bill for the skilled services being provided. Sometimes point-of-service documentation may be practical during a treatment session, but sometimes it may not.” (For more information, AOTA members can access "How to Reflect Practitioner Time in CPT® Codes" here.)
But if you have to completely stop treatment to document, you won't be able to bill for that time.
Tim Nanof, ASHA Director of Health Care Education & Policy said that "When there is an opportunity to document at the point of service-- for instance, with an EMR that makes it easier to do while providing treatment--it is encouraged." According to Nanof, the important thing is that "the documentation [doesn't] interfere with the quality of the services being provided."
Shelly Stangl, MS, OTR/L, President of AMeraSino, Inc., a company that provides regulatory compliance consulting for Medicare and Medicaid support facilities, says that "the key aspect of making [point-of-care documentation] billable time is that the clinician must be providing a skilled service simultaneously."
Dr. Eugene Freund, MD, MSPH, CAPT USPHS provided similar guidance. Dr. Freund is a medical officer on the Physicians Regulatory Issues Team in the Division of Professional Affairs for CMS, and he agreed that "as long as the therapist is providing cues or something like that, it's OK to type simultaneously if they're able to do that while still providing the cues, assessing the patient, etc."
Dr. Freund recommends checking with your Medicare Administrative Contractor (MAC) to be sure. (Find your MAC here.)
Now obviously it isn't always possible to document and provide a skilled service simultaneously. Some kiddos need a more hands-on approach.
PTs in particular may find that point-of-service documentation is more difficult, since their sessions often require constant communication and monitoring feedback.
But when you can document while still providing skilled services, documenting in real-time provides several benefits.
You Can't Bill for Supervision
When you practice point-of-care documentation, it's important to be aware of whether or not you're actually providing a skilled service. One trap that's especially easy to fall into when you're trying to complete documentation at the point-of-care is just giving your kiddo something to do while you finish your notes.
Medicaid does not consider that a skilled service. As this slideshow from the Centers for Medicare & Medicaid Services says:
"Services must not only be provided by the qualified professional ... but they must require, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently."
Make sure that you're not just giving your patient a distraction while you finish your documentation. (If you have to do that, don't bill for it.)
In this article by McKnight's Long-Term Care News, Stangl writes that if "the therapist completes point-of-service documentation on a clipboard or laptop while sitting within line-of-sight of the resident performing skilled activities," the therapist can bill for that time.
But this seems more like supervision to me. What do you think?
When Can You Bill For Time Spent Documenting?
Here's are some general guidelines on when billing for point-of-care documentation is appropriate:
-Can you document and provide the skilled service simultaneously?
-Is it practical to document while providing the skilled service?
-Can you document without interfering with the quality of the skilled service?
If you can answer "Yes", to those three questions, you should be able to bill for those minutes.
Talk to an Expert
This can be a tricky area, and I'm not a Medicaid expert. Before you bill for time spent simultaneously providing a skilled service and documenting, you should speak to an expert and/or your MAC.
I'd be interested to know other therapists' opinions on this issue. How do you feel about billing for time spent providing a skilled service while documenting?