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Clarice Grote, MS, OTR/L

Point of Service Documentation in Occupational Therapy: Billing, Ethics, and Medicare Guidelines

If you’re an occupational therapy practitioner, you’ve likely encountered the term “point of service documentation” (POS) at some point in your career. It’s a topic that can be both complex and controversial. In this post, we’ll delve into the world of point of service documentation and discuss when it is okay to bill for documentation… and when it’s not. 

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But first, a personal opinion:

Admittedly, I am generally supportive of the use of POS documentation with one major caveat – when it is appropriate! In home health, I found POS documentation both valuable for time management, for accurate documentation, and patient buy-in. 

It was a great opportunity to review what occurred during the session, explain the therapeutic reasoning behind the interventions, and gather patient feedback on their progress and if any adjustments needed to be made to their goals. 

Now, in acute care, I would take notes on paper for my evaluations but would not document in the actual chart. This was primarily a workflow issue though. If we had computers in each room, I certainly would have completed more POS documentation.  

All that said, I am adamantly against the use of point of service as a weapon in attempting to meet unrealistic and unreasonable productivity standards. It should also never be required unless there is some evidence-based purchase behind the requirement, and the use of POS documentation should never put a patient’s wellbeing at risk. 

So, with that said… let’s dive into what the regulation says about billing for documentation!

Episode 31: Billing for Point of Service (POS) Documentation

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What is Point of Service (POS) Documentation?

Point of service or POS documentation is the practice of documenting services while you’re with the patient. Typically, you are documenting in that patient’s record while with that same patient. It is also at times called point of care or POC documentation.

This is most common especially in skilled nursing facilities, outpatient settings, and during evaluations where it is necessary to document a lot of information. However, there are of course many times where point of service documentation is not appropriate or possible.

In the best world, point of service documentation is used to streamline the therapy process, enhance communication, and ensure accurate and up-to-date record-keeping. Other times, point of service documentation is used unethically to increase productivity, increase time billed with patients, and is not patient-centered. 

When Can You Bill for Point of Service Documentation?

Billing for point of service documentation is not a straightforward matter. While there are times that you can bill for documentation time, typically, you cannot. 

CMS says, 

“The therapist’s time spent on documentation or on initial evaluation is not included…Only skilled therapy time (i.e., requires the skills, knowledge and judgment of a qualified therapist and all the requirements for skilled therapy are met) shall be recorded”

MDS RAI Manual 1.17.1 p 507

The most crucial factor in determining whether or not you can bill for documentation time is ensuring that you are actively providing a skilled, reasonable, and necessary service to the patient while documenting. Simply documenting without actively engaging with the patient is not considered a billable service. Your focus should always be on the patient’s well-being and progress.

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Examples of Appropriate Point of Service Documentation

Reviewing Goals

While sitting with the patient, you can discuss their therapy goals, review their progress, and make any necessary updates to their treatment plan. This can be a great way to ensure a plan of care remains patient-centered.

Educating the Patient

If your point of service documentation includes educating the patient about their condition, goals, the purpose of occupational therapy, specific exercises, or interventions, it is typically viewed as a skilled service. Education is a valuable component of therapy and can help build patient buy-in and therapeutic rapport and ensures the client understands their role in the therapy process.

Monitoring Vital Signs, Measurements, or Responses

Another scenario where point of service documentation can be billable is when you are actively monitoring the patient’s vital signs or their responses to an intervention. This monitoring should be directly related to the patient’s treatment and must contribute to their overall progress. 

For example, this is especially helpful if assessing for orthostatic hypotension or when I would take measurements for range of motion, manual muscle testing, or lymphedema progress. 

Although this documentation is not necessarily “skilled”, it is part of the process of providing the skilled intervention because you have to write it down at some point, right? So as long as it is not taking up too much time, it is generally included in the billable time of providing care to the patient. 

Examples of Inappropriate Point of Service Documentation

Idle Chatter

Engaging in unrelated conversations or small talk that do not contribute to the patient’s care or progress while documenting or finishing up a previous patient’s note.

Non-Skilled Activities

Documenting while the patient is engaged in a non-skilled activity, such as using an exercise machine without active therapeutic involvement or skill required.

Documentation of a Different Patient

Billing for point of service documentation while actively treating a different patient is not ethically acceptable and can raise concerns about patient care quality. And you cannot bill for a service that does not take place with the patient you are billing. 

Using Documentation to Increase Billable Time 

Starting your documentation on your way to the patient’s room and reporting that under therapy minutes or billable time, it would be considered fraud and a violation of the False Claims Act, and you could use your license. 

The Ethical Perspective – Billing for Documentation

It’s essential to emphasize that billing for point of service documentation should always be approached ethically. Engaging in practices that could be interpreted as inflating billable time or defrauding payers and patients is not only illegal but also a violation of professional ethics.

If you are including time spent on documentation or on services that are not skilled or necessary, then you are essentially billing the patient for services that were not provided. I know I wouldn’t be happy if a provider did that to me, so I don’t want to do it to my patients. 

Remember that as an occupational therapy practitioner, your primary focus should be on delivering high-quality care that aligns with the patient’s needs and goals. Billing inaccurately or inappropriately can harm the reputation of the profession and contribute to increased regulations in therapy services.

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Point of service documentation in occupational therapy can be a valuable tool when used appropriately. However, it’s crucial to always prioritize patient care and ethical billing practices.

As a practitioner, it’s essential to use your clinical judgment to determine when point of service documentation is appropriate and billable. By doing so, you can maintain the integrity of the profession while providing the best possible care to your patients.

For additional resources and guidance on billing and documentation in occupational therapy, consider exploring the Amplify OT Membership, where you can access in-depth lessons and support on this topic. 

Remember, ethical practices and patient-centered care should always be at the forefront of your occupational therapy journey.

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Special thanks to Lindsay Bright, OTD for her contributions to this article.

Clarice standing in a light room smiling wearing black pants and a light green puff sleeve shirt

hi there,

I’m  Clarice

Occupational therapist & medicare specialist helping practitioners understand policy, engage in advocacy, and own their value!

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