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:

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.