As I mentioned in my last post on point-of-care documentation, documentation during treatment is widely recommended. But when it comes to billing, the RAI User’s Manual says that only skilled therapy time is billable and “[t]he therapist’s time spent on documentation or on initial evaluation is not included.”

Based on my interpretation of the rules, I would never do any documentation during sessions when I was starting out. I’d wait until later in the day (hopefully) or week (yikes!) to flip through my notes and start documenting the session.

This meant I’d end up with a growing pile of notes (not always legible, unfortunately). And as the top of the stack got higher and higher, so did my blood pressure!

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This is an opinion piece by a therapist at Fusion Web Clinic and should not be considered legal advice.

There’s a lot of confusion surrounding when (or if) it is appropriate for a pediatric therapist to bill for time spent on documentation. Some therapists say it’s never appropriate, and some don’t think twice about documenting during treatment and billing for it.

According to APTA’s Center for Integrity in Practice: “Documentation should be completed at the point of care or soon afterward,” and a list of documentation tips from OT managers compiled by AOTA also contains a tip recommending point-of-care documentation.

But when it comes to billing for treatment, the RAI User’s Manual says that only skilled therapy time is billable and “[t]he therapist’s time spent on documentation or on initial evaluation is not included.”

Is there a way to do both?

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