Testing billing documentation question over multiple days

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In my current clinic, I see patients for two hour blocks for testing.

I'm wondering what y'all include in your documentation for testing.

For instance, someone suggested putting "administered WISC-4 (60 minutes), and then psychological testing evaluation services (60 minutes).

That seems a little too minimalist.

Do y'all have any guidance?

 

[WisNeuro]

In general, I drop all of my billing on the same day. In my report, I list the days that I did interview testing, and the day of the feedback. It's rare to go testing a second day for me, but it does happen. Haven't had an issue with reimbursement yet. I do keep documentation of F2F testing start and stop times. but that's probably overkill, in case of an audit.

 

[AcronymAllergy]

I've seen multiple recommendations to do as WisNeuro mentioned and submit all billing on the same day once all services are done. That means waiting to submit the bill until feedback is completed, if you deliver feedback at a separate appointment.

It's a non-issue in VA generally, but I list dates of interview and testing (and would do the same for feedback if it were feasible in my system); start/stop times for interview and test administration; total time on testing (including scoring); and total amount of time on evaluation services (96132/96133). I also include a list of administered tests. I do not list time spent administering and scoring each individual test, nor do I list start/stop times for the eval services codes or for time spent scoring. If I start accepting Medicare and insurance, I might start being more specific with my documentation.

 

[WisNeuro]

I've seen multiple recommendations to do as WisNeuro mentioned and submit all billing on the same day once all services are done. That means waiting to submit the bill until feedback is completed, if you deliver feedback at a separate appointment.

It's a non-issue in VA generally, but I list dates of interview and testing (and would do the same for feedback if it were feasible in my system); start/stop times for interview and test administration; total time on testing (including scoring); and total amount of time on evaluation services (96132/96133). I also include a list of administered tests. I do not list time spent administering and scoring each individual test, nor do I list start/stop times for the eval services codes or for time spent scoring. If I start accepting Medicare and insurance, I might start being more specific with my documentation.

I haven't heard of this being required anywhere. But who knows what the future brings

 

[AcronymAllergy]

I haven't heard of this being required anywhere. But who knows what the future brings

I once had the VA, of all places, come back on one report years ago and ask for this. But I agree--for folks in the real world, it seems to be overkill.

 

[Justanothergrad]

+1 to others said. I document start/stop times to coverage total billable time - particularly if its an out of pocket/by hour assessment. Its never been an issue and I've never had pushback, but I like to do it to play safe. When billing insurance, I've dropped all bill codes at the same time as well but noted dates in report.