Tip #1: Pinnacol follows the Division of Workers' Compensation (DOWC) Rule 18, CPT® and AMA guidelines.

Tip #2: Clearly document therapy time.
Providers must clearly document the time spent performing each billed service as well as the beginning and ending time for each session. If this information is kept on the flow chart, this documentation must be submitted with the therapy notes.

Tip #3: Understand time intervals for therapeutic units of service.
CPT guidelines state a unit of service is attained when the midpoint is passed. Documentation must include at least eight minutes of service to bill for a 15-minute visit. Services performed for less than eight minutes should not be billed.

DOWC Rule 18 states that the total amount of billed unit time cannot exceed the total time spent performing the procedures. This means the total time for therapy is the maximum number of units to bill (using the midpoint billing rule).

For example, if the total time for all procedures in a day is equal to or greater than 23 minutes but less than 38 minutes, then two units should be billed. Any remaining time less than eight minutes per unit of service is not separately reported.

Providers familiar with Medicare billing may see some similarities; however, in Colorado workers’ compensation billing:

• The remaining time from one therapy may not be “carried over” to a different therapy code.
• The maximum allowance for services billed by a physical therapist assistant or occupational therapist assistant shall be 85% of the fee schedule.
• The maximum allowance for services billed by a massage therapist shall be 72% of the fee schedule.
• The total time for therapy includes time for all therapy codes billed on a given date of service.

‍

Time intervals for 1 through 5 units

Pinnacol conducts pre-and post-payment documentation reviews for therapy services. If your documentation does not support the services being billed, your request for payment could be denied or you could receive a letter requesting a refund based on an overpayment.

If you have questions, please contact us at 303.361.4940 / 888.852.2289 or billing_success@pinnacol.com