Point of Service Documentation and Other Billable Service Myths


Facebook forums have been abuzz lately regarding ethical versus unethical productivity requirements for rehab professionals in the skilled nursing facility (SNF) setting. Some therapists say 90%+ productivity, while challenging, is attainable and say they manage to hit those numbers regularly. Other therapists are adamant that productivity expectations of 90%+ are impossible. Ultimately, the issue of ethical versus unethical productivity comes down to Medicare regulations regarding skilled (billable) and unskilled (non-billable) services. This information, while readily available, is a bit difficult to track down and piece together. In this blog post, we’ll look at skilled and unskilled services as defined by Medicare and I challenge all of you to consider this information during your daily practice and to share with your colleagues.

Minutes of Therapy (p. O-19, Chapter 3 of CMS’s RAI 3.0 Manual)

Actions that can and can’t be included as minutes of therapy; applicable to all PT/OT/SLPs and assistants.

·         Therapist time spent on documentation or on initial evaluation is not included.

·         Therapist time spent on reevaluations, as part of the treatment process, is included.

·         Family education, conducted with the patient present, is included and must be documented in the resident’s record.

·         Time required to set up equipment and/or prepare for treatment is included. This can be completed by the therapist, therapy assistant, or therapy aide.

·         Only skilled therapy time (e.g. activities requiring the skills, assessment, and knowledge of a qualified therapist) are included. If a therapist conducts an activity which includes skilled and unskilled time, only skilled time may be included.

·         Therapy time delivered by qualified COTA/PTAs are included only if the assistant is under the direction of a qualified PT/OT. Medicare does not recognize SLP assistants.

·         Actual therapy minutes are included. Rounding minutes is not permitted.

·         Time spent persuading a resident to participate in therapy, when they are refusing, is not included.

I bet many of you are thinking, “Whoa! What about my company’s point of care (POC) requirements? I was always told this was a billable service!” Every company I’ve worked for pushed the idea of completing all documentation in the presence of the patient, in an attempt to raise employee productivity. As you can see, the Centers for Medicare and Medicaid Services (CMS) clearly state time spent on documentation is NOT to be included in minutes reported as therapy. It is interesting that these government regulations are public domain, yet many facilities blatantly disregard them. When these regulations are disregarded, fraud is committed. Does that seem like an extreme statement? It’s not. It’s not even an interpretation of the rules or my opinion regarding the regulations. The regulations very clearly state what may and may not be included on the MDS (minimum data set) as billable therapy minutes. Not complying with those regulations means you are submitting time that the CMS has defined as not included on the MDS; which equates to fraudulent billing.

Okay, let’s get back to discussing the topic of this blog post: productivity. When the above regulations are taken into consideration, lets think about all the things therapists typically must complete during the workday that are not permitted to be included as billable service (adapted from Grey Matter Therapy’s blog - http://graymattertherapy.com/its-worse-than-i-thought/):

·         Printing out your schedule and getting ready for the day. (Reading email, responding to email, gathering therapy materials, etc.)

·         Calling families to update on status and recommendations for discharge planning.

·         Waiting for patients to be ready for therapy. (Such as patient’s getting dressed, going to the bathroom, episodes of incontinence, visitors arriving, breathing treatments, doctor arrival, med pass… the list goes on.)

·         Attend care plan meetings with families, nursing staff, social worker, doctor, etc. to discuss status and discharge planning.

·         Complete screenings of patients who have been admitted to the building recently, annual screenings, or nursing concerns.

·         Complete evaluations and obtain standardized scores.

·         Write up evaluations, discharge summaries, weekly progress notes, 30-day recertifications, etc.

·         Attend therapy team meetings to discuss status, collaborate to improve patients’ outcomes, etc.

·         Consult with other professionals (SLPs, social workers, psychiatrists, psychologists, etc.) regarding complex patient cases.

·         Write orders updating treatment frequency and duration.

·         Write orders and educate nurses and CNAs regarding diet texture and consistency changes.

·         Obtain patient records from modified barium swallow studies, prior speech therapy, gastrointestinal specialists, otolaryngologists, etc. to update plan of care.

·         Problem solve behavior and communication challenges and train nurses and CNAs to provide appropriate level of cueing and assistance to maximize independence and while maintaining safety.

·         Complete in-service trainings with new staff or current staff at regular intervals to ensure that appropriate referrals are being made and staff is equipped with skills to manage dysphagia and cognitive-communication disorders, etc.

·         Troubleshoot computer and documentation software issues.

·         Supervise graduate student interns or clinical fellows.

·         Complete company required continuing education.

·         Reading email and written notes from managers (often about failure to meet productivity expectations) or having meetings with managers about failure to meet productivity requirements.

·         Performance reviews and other human resources related activities.

·         And lastly, heaven forbid, using the restroom or having a bite to eat. (Just kidding, we all know this isn’t billable. But wouldn’t it be nice to have as a part of your day?)

That’s an awful lot of important, patient-centered care tasks that Medicare does not recognize as billable service. These tasks take time and are necessary to provide the care patients in SNFs are entitled to have. The fact that Medicare does not recognize the above as billable time is a shame, but it is what it is. Given that these tasks must be completed during a work day because they are necessary for patient care, lets take a peek at what an 8-hour day with a 90% productivity requirement looks like.

8 hours = 480 minutes  

90% of 480 minutes = 432 minutes          

480-423 = 48 minutes non-billable time

As a speech-language pathologist (SLP), my treatment sessions are typically 30-45 minutes per patient. Given 432 minutes of treatment time, I could hypothetically see 13 patients for 33 minutes and 1 for 36 minutes, for a total of 14 patients seen. Since I’m not able to magically teleport to my patients’ rooms, I’m going to allow for 3 minutes between patients; accounting for a total of 39 non-billable minutes. Now I’m left with 9 minutes of non-billable time. Amazing! I might get to take a bathroom break! Oh, never mind… I have orders to write, documentation to complete, staff to educate, and on and on.

Tell me again how attaining 90%+ productivity is possible, given the regulations stated above. Just considering the time it takes to move from patient to patient, most of my calculated non-billable time is gone! 90%+ productivity expectations in the SNF setting are frankly ridiculous and put therapists in positions where they must ethically compromise themselves to please administration. Administration doesn’t care about therapists being ethically compromised because, at the end of the day, the responsibility of ethical billing falls on the therapist. It’s not possible to lose your license due to not meeting your facility’s productivity requirement. However, you can lose your license if you submit fraudulent therapy minutes for Medicare billing.

Food for thought.


Recommended Readings:

MDS 3.0 RAI Manual v115:


Every Minute Counts:


Under Pressure:


Counting the Clock: 7 Must Know Facts About Billable PT Treatment Time:


It’s Worse Than I Thought: