Medicare 8-Minute Rule WITH Examples
In the therapy world, treatment sessions are measured and reimbursed based on the amount of time spent performing a single intervention, something also known as billable units. Depending on what setting you are practicing in, you most likely have encountered patients with Medicare insurance. In order to prevent fraud and abuse of services, Medicare has specific rules and regulations in place which must be strictly adhered to in order for a clinic to be reimbursed for their provided services. When billing for rehabilitation services, the CMS (Centers for Medicare and Medicaid Services) requires therapists to follow the 8-minute rule.
According to this CMS Manual, “For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.” If the CMS discusses billing in 15 minute units, then why is it called the 8-minute rule? Excellent question. The reason for this is that in order to charge for one unit, the rehabilitation provider must be in direct contact with the patient for at least 8 minutes.
Now you may be asking yourself, “okay, so if I treat a patient for 16 minutes then I should be able to bill 2 units, correct?” Unfortunately, no. If you provide between 8-22 minutes of treatment to a patient, then that still only counts as one unit so technically, it’s the 8 + 15-minute rule! Also, good to note is that the 8-minute rule only applies to time-based CPT codes, not service-based CPT codes. You can learn more about time-based vs service-based CPT codes and see the 8-minute chart here.
Since reading about the 8-minute rule is sometimes overwhelming and more confusing than helpful, let’s discuss some applicable examples.
Let’s say you provide:
15 minutes of therapeutic activity + 10 minutes of therapeutic exercise = 25 total treatment minutes
Since you have surpassed 22 minutes, you have successfully provided 2 billable units so you would bill for 1 unit of therapeutic activity and 1 unit of therapeutic exercise.
Let’s say you provide:
10 minutes of therapeutic activity + 10 minutes of manual therapy + 10 minutes of cold pack = 20 total timed treatment minutes
In this scenario, a cold pack is considered a service-based code meaning you bill 1 unit for it, regardless of how long you provide the modality for. Service-based codes also do not count towards your total timed treatment minutes. Now, let’s look at the timed codes. Since the total timed treatment adds up to 20 minutes, you only have 1 billable unit. In this case, since equal treatment time was provided for therapeutic activity and manual therapy, it is up to the therapist to decide which CPT code they want to bill. Typically, most therapists will choose to bill the CPT code with the higher reimbursement rate, which in this example would be therapeutic activity.
Note: If the therapist spent 11 minutes on manual therapy and only 9 minutes on therapeutic activity, then they should bill manual therapy since more time was spent performing that CPT code.
Example 3- Remainder Rule:
Let’s say you provide:
12 minutes of therapeutic activity + 22 minutes of neuromuscular re-education + 7 minutes of therapeutic exercise = 41 total timed minutes
Here’s where it gets tricky because the remainder rule comes into play. Because you have 41 total timed minutes in this example, you will bill for 3 units. 1 unit will be therapeutic activity and the other 2 units will be neuromuscular re-education. Now, you might be saying to yourself, but “there was only 22 minutes of neuro re-ed which means it should be only 1 unit”. However, that is incorrect due to the remainder rule. Since therapeutic exercise is a timed code, those 7 minutes play into the total timed minutes and because Medicare billing is based on the total timed minutes, you bill for 3 total units. In this scenario, 2 of those units have to be neuromuscular re-education since the therapist did not provide at least 8 minutes of therapeutic exercise.
A good rule of thumb to remember when billing based on the 8-minute rule is to always bill based on the total timed treatment minutes so that as a therapist, you do not end up underbilling Medicare for the session.
Billing based on the 8-minute rule can often be confusing and time consuming for most therapists, especially if the remainder rule is in play and the therapist does not fully understand it. The best way to avoid a costly underbilling mistake is to use an EMR documentation and billing system, such as HelloNote, which offers built in calculators and assistance that will correctly bill for you so that you, as a therapist, can focus on what matters most…treating your patient!