Question
If a patient refuses therapy on one of their treatment days and the therapist documents this, would that count as a visit for five consecutive days since the therapist did attempt and documented that the patient refused?
Answer
Unfortunately, the answer is no. You must provide a minimum of 15 minutes treatment time to qualify it as an actual visit. If the patient refuses and you do not provide any actual treatment with the patient, then you have to bill “0” for that day and it will not count as a visit. Many companies have policies encouraging therapists to use that “refusal of actual treatment” to provide patient-caregiver education. If you can provide at least 15 minutes of education with the patient, they may be willing to participate in the educational session. You can educate them on their discharge plans, updating their current plan of care, talk to them about the benefits of therapy, their goals, and what kind of progress they have been making. That will count as actual treatment time and then you could bill the 15 minutes. But if they completely refuse and you have 0 to bill for the day, you cannot count that as an actual visit.
Shelly A Mesure, MS, OTR/L, is a nationally recognized industry expert and speaker specializing in training and seminars throughout the United States on translating government regulations to everyday clinical practice. She is also the SVP of Orchestrall Rehab Solutions providing on and off-site consulting services throughout the US and China.
