In the classic 1993 legal flick The Firm, Gene Hackman’s veteran attorney character advises a rookie associate (played by a young and dashingly handsome Tom Cruise) to bill for any hours he spends “even thinking about a client”—whether he’s “stuck in traffic or shaving or sitting on a park bench.” Unfortunately, the rules governing billable time in rehab therapy are not as, shall we say, open to interpretation. In fact, billing for every single minute of a patient visit would be a serious red flag, because it would be nearly impossible for a therapist to run an entire session of pure, continuous billable time.

So what makes a minute billable? In most cases, as this document explains, “The time counted is the time the patient is treated.” But sometimes, the answer to the ubiquitous “to bill, or not to bill” question is not so cut-and-dried—especially with the Internet’s abundant supply of misinformation and conflicting advice. Here, I’ve compiled some plain-English clarifications to some of the most common billable time conundrums. (Please note that while this guide covers Medicare guidelines specifically, many third-party payers employ similar billing policies. Still, I strongly recommend verifying the rules for each insurance your clinic accepts.)

1. You can’t bill for unskilled prep time.

Medicare reimburses for skilled time only. Thus, any unskilled time dedicated to preparing a patient or treatment area for therapy cannot be counted as billable time, even if you, the licensed therapist, are completing those tasks. As this document advises, “…time counted as intraservice care begins when the therapist or physician or an assistant under the supervision of a physician or therapist is delivering treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.”

The same rule applies to unskilled clean-up time. However, as noted in this blog post, there are certain instances in which post-treatment time qualifies as “skilled,” meaning you can bill for it: “checking the patient’s skin for damage upon electrode removal would be considered skilled therapy, making it billable time.” Furthermore, as Mary Daulong, PT, CHC, CHP, explains here, if there is a reason for you to provide a skilled service during a clean-up period—for example, checking the blood pressure for a patient who becomes physiologically unstable and is incontinent during the treatment session—then you can bill for the time you spend providing the skilled service. So, in this particular example, you could bill for the time it took to check the patient’s blood pressure.

2. You can’t bill multiple timed units due to the presence of multiple therapists.

If a single patient is receiving a single unit of treatment, you can only bill for that one unit—regardless of how many therapy professionals contributed to the delivery of that treatment. For example, as this resource advises, “…if gait training in a patient with a recent stroke requires both a therapist and an assistant, or even two therapists, to manage in the parallel bars, each 15 minutes the patient is being treated can only count as one unit of 97116.”

3. Rest periods and other break times are not billable.

Unless your patient population is an army of Energizer Bunnies, they’re probably going to need some recovery time between treatment activities. Unfortunately, those breaks aren’t billable. As this document clarifies, time spent “toileting or resting” doesn’t qualify as billable, and neither does “the time spent waiting to use a piece of equipment or for other treatment to begin.”

4. You can’t bill for supervision.

Any time you spend supervising a patient who is performing a therapeutic exercise program independently isn’t considered billable, as this CMS document makes clear: “Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service.”

5. “Rounding up” is a no-no.

Rounding might seem like a convenient—and mostly harmless—way to simplify your billing calculations. But to an auditor, a constant stream of perfect 15-minute treatment increments looks pretty fishy—and it could lead to billing for more skilled time than you actually logged with a patient. Remember, when it comes to recording treatment time, almost doesn’t count; in other words, if you provided a particular timed treatment for 14 minutes, that’s how many billable minutes you should record. “Both treatment times and session times should be recorded to the exact minute,” this article states.

Now, per Medicare’s 8-minute rule, you can bill for a full 15-minute timed treatment unit as long as you provided that service for at least 8 minutes, but as this blog post explains, it’s still imperative that you record the exact duration of each type of treatment you provide.

6. You can bill for evaluations and re-evaluations in some cases.

Most payers, including Medicare, allow therapists to bill for the initial evaluations necessary to establish plans of care. (However, please note that, according to this ADVANCE article, therapists billing under Medicare Part A in a skilled nursing setting cannot bill for the “time it takes to perform the formal initial evaluation and develop the treatment goals and the plan of treatment cannot be counted as minutes of therapy received by the beneficiary.”)

As for re-evaluations, therapists can bill for the time they spend conducting these mid-POC assessments if “some kind of significant change has taken place regarding the patient’s progress and, therefore, his or her plan of care (POC).” For more detailed guidance on billing for re-evals, check out this blog post.

7. You can’t bill for documentation.

Documentation takes time—there’s no denying that. Even if you have an EMR system that streamlines the process, there’s still a lot of effort that goes into creating notes that are complete, correct, and compliant. Unfortunately, you won’t get paid for that effort, because as Pauline Watts, MCSP, PT, and Danna D. Mullins, MHS, PT, explain in this article, “Documentation time alone is not considered billable time under Medicare regulations.” The key word, however, is “alone”; the article goes on to explain that in some cases, you may be able to provide billable services at the same time you are documenting. Case in point: patient education, which includes any time dedicated to “discussing progress in therapy with the patient, including improvement in objective measures and how they are progressing toward their goals,” Watts and Mullins write. “If we are documenting this patient education information at the same time we are providing it to the patient, then this documentation time can be included in the treatment time.” One major caveat: the patient must actively participate in the conversation. That is, he or she cannot just sit passively and listen as you read or dictate your notes out loud. “Obviously not all documentation can be done in this manner and not all patients are appropriate to include in this educational process,” Watts and Mullins continue. “[But the] practice of sharing the information with the patient has many extremely positive outcomes for the patient.”

Thanks in part to Hollywood, lawyers have earned a bad rap for inflating their timesheets. (I’m looking at you, Hackman.) Rehab therapists, on the other hand, are more likely to leave money on the table due to confusion over what counts as billable time. Are you getting the most out of your minutes? What questions do you have? Let us know in the comment section below.