By John Wallace, WebPT
When it comes to securing proper payment for medical services, most providers do all they can to increase their effectiveness. Double-checking insurance eligibility, using quality billing software and documentation technology, and coding claims with precision can help practices get the highest reimbursement for their services. However, some providers are still leaving money on the table.
Currently, many clinicians—like rehab therapists—who utilize timed CPT codes are not including assessment and management time when considering their billable time, and that’s a direct result of the confusion surrounding this topic. The reality is, they can—and should. By neglecting to include assessment and management time, they not only reduce their profit, but also undervalue their services.
When it comes to billing, what you think and say to patients is just as important as what you do. Here are a few things you need to know to be sure your billing reflects the important service you provide to patients.
Many rehab therapists do not bill for the entirety of their time with patients because they mistakenly discount their assessment and management time, opting instead to only record the time spent administering hands-on treatment to a patient. While there is no separate coding for it, the minutes associated with assessment and management are indeed part of the service you provide—and must be accounted for as such.
According to the American Medical Association (AMA) CPT Editorial Panel and RBRVS Update Committee—who are responsible for the code definitions and the fee schedule relative value for the services rehab therapists provide—face-to-face time is considered treatment time. As such, all face-to-face assessment and management activities providers do to support the delivery of an intervention are included. For example, answering a patient and/or caregiver’s questions about their treatment, assessing a patient before performing a hands-on intervention, assessing a patient's response to an intervention, documenting in the presence of a patient, or providing instructions about at-home self-care all fall within this category.
While the future may hold AI solutions to streamline billing and healthcare IT, as of now, it’s up to practices to uphold compliance through detailed documentation. To receive payment for the entirety of your services, the documentation must not only describe the interventions you provide; it must also include a description of the clinical guidance you delivered to the patient
As with documenting any billable time, it’s important to make your entries defensible, meaning that you clearly describe the treatment and the clinical reasoning behind it. Be sure to include a report of patient progress, any changes made to a treatment plan, clinical reasoning, discussions with patients or caregivers, and changes to any treatment plan goals.
An electronic medical record (EMR) that integrates with your billing software can help streamline the documentation and billing process. Integrated systems can reduce coding errors and provide easily accessible documentation attachments and improved access to financial data—all of which can improve reimbursement rates. Most importantly, though, a streamlined system helps providers save time so they can focus on doing what they do best — healing patients and providing a positive patient experience.
At the end of the day, assessment and management are skilled services that require you to use your clinical expertise. It’s important to bill for these activities—not only to ensure appropriate payment for your time but also to demonstrate the value you provide to your patients.
John Wallace, PT, MS has more than 35 years of experience in private practice orthopedics as well as leadership in health IT, revenue cycle management, billing, acute hospital, acute rehab, home health care, and other specialties. He currently serves as the Chief Business Development Officer of Revenue Cycle Management at WebPT. He has been invited to speak at numerous national healthcare events on the topics of payment policy, compliance, practice management, and rehabilitation economics and is a coding and payment policy consultant to several APTA components.