There’s a lot of confusion around whether PTs can bill for assessment and management time. The short answer is “yes,” PTs can—and should—account for assessment and management time in their billing and documentation. Yet, as it stands, many PTs don’t. And that’s a shame—because in failing to do so, they are not only leaving money on the table, but also seriously undervaluing their services. In other words, if you’re not billing for assessment and management time, there are consequences to your practice—and the profession. With that in mind, here’s what you need to know about billing for your highly skilled assessment and management time:

The 2018 Rehab Therapy Salary Guide - Regular BannerThe 2018 Rehab Therapy Salary Guide - Small Banner

A timed CPT code accounts for more than hands-on intervention.

According to John Wallace, WebPT’s Chief Business Development Officer of Revenue Cycle Management (RCM), “when it comes to billing, what [you] think and say to the patient [are just] as important as what you do.” And CPT codes reflect that. In fact, Wallace says that when you bill for a service with a timed CPT code, that code includes:

  1. “The hands-on part of the intervention named by the code (e.g., therapeutic exercise);
  2. “The supplies required to deliver the intervention; and
  3. “The assessment and management time necessary to deliver the service.”

As Wallace explained, “the American Medical Association (AMA) CPT Editorial Panel and RBRVS Update Committee are responsible for the code definitions and the fee schedule relative value for the services [PTs] deliver to [their] patients and clients.” And according to these groups, treatment time is face-to-face time. “For timed CPT codes, that means that only the minutes we spend face-to-face with our patients are billable,” Wallace said. “But, many therapists do not bill for all of [their] facetime minutes because they undercount their assessment and management time with patients.”

Assessment and management time counts as face-to-face time.

According to Wallace, “assessment and management time activities include all the things you have to do to deliver an intervention,” such as:

  • assessing the patient prior to performing a hands-on intervention;
  • assessing the patient’s response to the intervention;
  • instructing, counseling, and advice-giving about at-home self-care;
  • answering patient and/or caregiver questions about the patient; and
  • documenting in the presence of the patient.

Given the last bullet, Wallace advises providers to “take the time to document your:

  • “clinical reasoning;
  • “changes you make in the treatment plan;
  • “any discussion you have with the patient;
  • “progress toward plan of care goals; and
  • “changes in the treatment plan you intend to make in upcoming patient visits.”

Documentation is key to compliantly billing for assessment and management time.

Furthermore, according to Wallace, “Your documentation is critical to justifying the inclusion of assessment and management minutes [as] part of the time attributed to your total one-on-one time.” In other words, your documentation must tell the story of more than the interventions you provide; it must also include the clinical expertise and guidance you provided to your patient—if you want to receive payment for the entirety of your services, that is.

Here’s an example:

Earlier this year, WebPT published a complete guide to defensible documentation. In it, we presented an entire example scenario, along with documentation notes that comprehensively captured assessment and management time—and notes that did not. (Remember: Your documentation must justify all aspects of the care you provide in order to receive payment.) While you’ll have to download the full guide to see the scenario in its entirety, here’s a sample:

Scenario:

“A 58-year-old woman is receiving outpatient physical therapy services for adhesive capsulitis of her left shoulder that interferes with her ability to babysit her three-year-old and one-year-old grandchildren.” One of the services provided during the patient’s last visit was therapeutic exercise. Below are two versions of the therapist’s notes. On the left, you’ll find language that doesn’t properly account for assessment and management time (not defensible)—and on the right, you’ll find language that does (defensible).

Not Defensible

Code

Defensible

  • Passive ROM flexion, internal rotation, external rotation - 10 reps each x 2 sets
  • Scapulothoracic mobility - 10 reps each x 2 sets

97110 (therapeutic exercise)

Therapeutic exercise to develop strength, endurance, range of motion, and flexibility

  • Passive ROM flexion, internal rotation, external rotation - 10 reps each x 2 sets; manual cues needed to avoid substitution with trunk; provided written HEP instructions for flexion and external rotation techniques using wall (5 reps each); repeat demonstration indicates patient safe to perform independently
  • Passive scapulothoracic mobility, all planes - 10 reps each x 2 sets; educated patient about GH joint biomechanics

The bottom line is that assessment and management are skilled services that you provide to your patients during their visits—in addition to hands-on interventions. Thus, they’re part of the value you provide to your patients. And you can—and should—bill for these activities. Does your practice bill for assessment and management time? If not, why? Share your experiences in the comment section below.

  • How to Discuss Medical Bills and Insurance with Your Patients Image

    articleApr 7, 2017 | 5 min. read

    How to Discuss Medical Bills and Insurance with Your Patients

    Buying health insurance is easier—and faster—than it’s ever been. Much like fast food, however, speedy convenience now can cause plenty of woe later. (For example, I’m betting a good portion of your patients purchased plans without even knowing how a deductible works for health insurance—let alone what their deductible actually is.) But as unpleasant as a post-taco-run stomachache can be, surprise medical bills are much more painful. I’ll take the #2 with the large deductible. Does this …

  • Common Questions from Our Patient Sticker Shock Webinar Image

    articleMar 31, 2017 | 33 min. read

    Common Questions from Our Patient Sticker Shock Webinar

    From copays and deductibles to payer contracts and benefits verification, understanding all the nuances of third-party insurances is tough enough for healthcare providers—let alone their patients. In WebPT’s most recent webinar— Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans —co-hosts Heidi Jannenga, PT, DPT, ATC/L, the cofounder and president of WebPT, and WebPT CEO Nancy Ham provided a lot of great advice on how to have productive conversations about healthcare costs with your patients—without …

  • The PT Patient's Guide to Understanding Insurance Image

    downloadApr 3, 2017

    The PT Patient's Guide to Understanding Insurance

    Patients are shouldering a greater portion of their healthcare costs than ever before. But when they don’t know the specifics of their coverage, they can end up with much bigger bills than they bargained for—and that often leads to unpaid balances and unfinished treatment plans. Bring them up to speed—and improve your practice’s collections and patient retention—with this guide. Patients will learn: What it means for a service to be “covered.” How to define common insurance terms. …

  • Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans Image

    webinarFeb 23, 2017

    Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans

    Copayments, coinsurances, unresolved balances—oh my! Any one of these can cause headaches for healthcare providers, but as healthcare reform efforts shift more and more financial burden to insurance beneficiaries, today’s practitioners are increasingly facing all three. And these challenges are not only hurting their patient acquisition and retention rates, but also their bottom lines. Tired of spending time verifying benefits only to lose those patients to copay sticker shock? Stuck in a constant cycle of pursuing past-due …

  • Insurance Coverage Confusion: Why Uninformed Patients Lead to Unpaid Balances Image

    articleApr 17, 2017 | 5 min. read

    Insurance Coverage Confusion: Why Uninformed Patients Lead to Unpaid Balances

    People buy lots of products without truly understanding how they work. But unlike that automatic wine corker you impulse-bought from Brookstone last month, not every purchase comes with a 20-page instruction manual—or ends up working the way we imagined it would. For many consumers, that frustration definitely applies to the health insurance selection process. And that’s especially true for those who are new to the insurance market —for example, the millions of Americans who recently gained access …

  • Aging Out: A/R Basics for Rehab Therapy Practices Image

    articleJul 10, 2018 | 5 min. read

    Aging Out: A/R Basics for Rehab Therapy Practices

    Some folks say the best things in life are free. While that may be true in many cases, in a rehab therapy practice, the best things ( like keeping the lights on , for instance) require cash money. But as any practice manager or biller knows, cash flow from paid claims isn’t always consistent. Between fluctuating reimbursements and aging claims, keeping track of your clinic’s revenue can be a full-time job—especially if you don’t have an efficient …

  • 5 Reasons You Should Attend Ascend 2015 Image

    articleApr 28, 2015 | 4 min. read

    5 Reasons You Should Attend Ascend 2015

    Have you heard? Ascend— the ultimate business summit for rehab therapists —is back. Last year, the inaugural event took Dallas—or at least, Dallas physical therapists and private practice owners—by storm for one jam-packed day . This year, Ascend is upping the ante—big time. For starters, our 2015 event will run for two days instead of one—and trust us, you don’t want to miss it. Here are five reasons you should attend Ascend 2015: 1. You’ll earn CEUs. …

  • 4 Subtle Ways You're Killing the Patient Experience Image

    articleJun 22, 2018 | 6 min. read

    4 Subtle Ways You're Killing the Patient Experience

    A positive patient experience is essential for instilling confidence and security in your patients—and for sustaining a healthy practice. When patients feel rushed, dismissed, or expendable, they’ll often drop out prematurely —and possibly seek care from a different PT (or move on to a whole other discipline). With that in mind, here are some of the common ways you’re subtly sabotaging the patient experience that you work so hard to create in your practice: 1. Providing a …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.