How is data “gathering” captured when performing assessment activities for billing purposes?
A review of the necessary records in the home when the service recipient and staff are present for input is billable. However, records not required to be included in the home record may not be transported from other locations to the service recipient’s home for the purpose of increasing reimbursement. Time spent reviewing records at other locations, such as provider agency offices, are not billable. In addition, documenting specific clinical data gathered via hands-on techniques or through observation of the service recipient during the assessment is also billable. Contact notes to indicate what assessment components were completed with the time-in and time-out documented are necessary for reimbursement to be provided.
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