The Medicare 8-minute rule applies to outpatient rehabilitation services such as physical therapy. This rule helps providers determine who many billable units of time they can submit to their patient’s Medicare insurance. This applies to treatment codes that are time-based, not service-based.
To understand how Medicare’s 8-minute rule works, we’ll need to know a little bit more about medical codes and how services are billed to a patient and their insurance.
Service-Based versus Time-Based CPT Codes
CPT stands for Current Procedural Terminology. Service-based CPT codes are used for things like physical therapy exams, unattended electrical stimulation, or applying hot/cold packs. Service-based CPT codes are billed as one unit, no matter how much time was spent delivering the treatment.
Time-based CPT codes are for procedures that require one-on-one, uninterrupted treatment. This would include manual therapy, gait training, ultrasounds, therapeutic exercises and activities, iontophoresis, and unattended electrical stimulation. Time-based CPT codes allow the provider to bill multiple units of treatment.
Providers Who Use Time-Based CPT Codes
There are several types of providers that employ Medicare’s 8-minute rule. This includes those at private practices, skilled nursing facilities, home health agencies, rehabilitation facilities, and hospital outpatient services.
All of these providers are seeing their patients in person and on an outpatient basis.
Calculating Billable Units and the Medicare 8-Minute Rule
Providers such as physical therapists who use CPT coding must follow a set of rules. One of those rules is Medicare’s 8-minute rule.
This rule allows providers to bill one unit of service to Medicare if that service lasts for at least eight minutes and up to 22 minutes. A billable unit of service refers to the time spent performing the service. After the initial eight minutes, each unit is billed in 15-minute intervals.
The billable units are broken down like this:
- 0-8 minutes: no charge
- 8-22 minutes: 1 unit
- 23-37 minutes 2 units
- 38-52 minutes: 3 units
- 53-67 minutes: 4 units
- 68-82 minutes: 5 units
- 83-97 minutes: 6 units
- 98-112 minutes: 7 units
- 113-127 minutes: 8 units
For example, if Doris had an ultrasound that lasted 9 minutes and manual therapy that lasted 28 minutes, the total billable units would be two units. If John attended electrical stimulation for 27 minutes, manual therapy for 34 minutes, and then asked questions to his therapist for 12 minutes, the total time spent would have added up to 73 minutes, or five billable units.
Other Programs That Utilize the 8-Minute Rule
Medicare is not the only program that uses the 8-minute rule for time-based CPT codes. Medicare, TRICARE, and CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) all use the 8-minute rule. While not the majority, some commercial insurance plans also utilize the rule. When Medicare is the payer, providers are required to abide by the rule.
Why You Should Understand Medicare’s 8-Minute Rule
If you’re not the provider, you may wonder why you should understand the 8-minute rule. After all, you’re not the one billing the Medicare program! However, the provider’s ability to bill by using the 8-minute rule may impact the bill you receive for the services.
It’s not uncommon for even providers to not completely understand the 8-minute rule. Oftentimes, this translates into under-billing the Medicare program. Of course, your providers should be paid what they earn, and you should NOT be left paying for any services you did not get!
Understanding how your insurance works may not be the most fun studying you’ll ever do, but it could pay off at times. It will also help you understand how your healthcare costs are calculated and allow you to plan for future expenses.