Documenting Time in Medical Records

WPS Medicare has noted Comprehensive Error Rate Testing (CERT) errors assessed due to missing documentation of time spent with the beneficiary for Individual Psychotherapy and Critical Care services, missing treatment time for Physical Medicine and Rehabilitation and missing the total duration of time spent for final Hospital Discharge of a patient. Medicare may request a refund of any payment made for time not documented appropriately.

Individual Psychotherapy Services

Because reimbursement of individual psychotherapy services is based on face-to-face time spent with the patient, practitioners are required to document in the medical record the time spent with the patient and bill the code that accurately reports the service performed. For further guidance on the proper billing and documentation of these services, refer to WPS Medicare's Local Coverage Determination (LCD) L30489 - "Psychiatry and Psychology Services".

Critical Care Services

Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. The duration of critical care services to be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured patient's care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as the physician is immediately available to the patient.

For further guidance on the proper billing and documentation of these services, refer to the CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 12, section 30.6.12Adobe Portable Document Format - Critical Care Visits and Neonatal Intensive Care (Codes 99291-99292).

Discharge Day Management Services

Hospital discharge day management codes 99238 and 99239 include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on the date is not continuous, discharge records, prescriptions and referral forms. As a reminder, discharge management must include documentation of a face-to-face evaluation and management (E/M) service between the attending physician and the patient.

Physicians must use the total duration of time spent in order to select the code that reflects hospital discharge day management services provided for Medicare beneficiaries. For this reason, the provider must clearly indicate in the patient's medical record the total duration of time spent when performing these services. For hospital discharge day management; 30 minutes or less, use CPT code 99238. To report 30 minutes or more, use CPT code 99239. To learn more about these and other Evaluation and Management (E/M) services, visit our E/M webpage.

Physical Medicine and Rehabilitation

Providers report the code and appropriate units for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. The time counted is the time the patient is treated and appropriately documented in the medical record.

To learn more about determining what time counts towards 15-minute timed codes for Physical Medicine and Rehabilitation codes, please refer to the CMS Internet-Only Manual, Publication 100-04, Chapter 5, Section 20.3Adobe Portable Document format.

Page Last Updated: Thursday, 09-Feb-2012 15:20:48 CST