Although the physician doesn't documents strength and endurance it is known that the purpose is to increase strength, range of motion and flexibility, so you can bill this code. This a time based code so time spent “supervising” a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the “Timed Code Treatment Minutes.” Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.
The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. This codes should not be reported no more than 4 units per day per discipline.
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. These documentation should include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, the time of any assessment is included and billed within the appropriate treatment intervention CPT code.
Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation.