Tip #1: Pinnacol follows DOWC Rule 18 and CPT/AMA guidelines.
Tip #2: Clearly document therapy time.
Providers must clearly document the time spent performing each billed service and the beginning and ending time for each session. If this information is kept on the flowchart, 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 reported.
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 rule).
For example, if the total time for all procedures in a day is equal to or greater than 23 minutes and 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.
- The remaining time from one therapy may not be "carried over" to a different therapy code.
- The DOWC does not reduce the fee schedule on therapy reimbursement. Therapy bills are processed at 100% of the fee schedule for each therapy or modality.
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 firstname.lastname@example.org