Submitted on Tue, 07/02/2024 - 14:52

United Healthcare has published an updated Habilitative Services policy that eliminates ambiguity regarding required "time-in and time-out" documentation. The Payer has made the following change in their policy:

Treatment Session Notes

Replaced “start and stop time in treatment” with “accurate documentation of the length of treatment session"

The new policy states the following requirements for claim submission:

Treatment Session Notes

All treatment session notes must include:

  • Date of treatment
  • Specific treatment(s) provided that match the CPT code(s) billed
  • Accurate documentation of the length of treatment session
  • The individual’s response to treatment
  • Skilled ongoing reassessment of the individual’s progress toward the goals
  • All progress toward the goals in objective, measurable terms using consistent and comparable methods
  • Any problems or changes to the POC
  • Member or caregiver involvement in and feedback about home program activities
  • Signature and date of the treating provider

Thank you to all APTA Private Practice members who advocated with the payer for the change!