Figuring out billing issues when you’re on Medicare can prove to be a challenge. Doctors charge different prices, and other procedures and tests cost extra. However, there is a rule you should know about that can affect how much you pay for services. It’s called the Medicare 8 Minute Rule.
The Medicare 8 Minute Rule gives health care providers the right to bill you the cost of a full unit of service if a visit lasts a minimum of eight minutes. As a rule, it is not hard to figure out how much to pay for products and some services. However, when it comes to Medicare, certain services and practitioners adhere to the 8 Minute Rule.
But what exactly is the 8 Minute Rule, and how does it affect you? Also called the Rule of Eights, the Medicare 8 Minute Rule was made known to the public in December 1999 and was implemented on April 1, 2000. The 8 Minute Rule establishes the number of units that can be billed for “timed services” that are provided in skilled nursing facilities, rehabilitation centers, outpatient departments in hospitals, and home health agencies that provide therapy through Medicare Part B.
If the duration of services lasts for a minimum of eight minutes and fewer than 22 minutes, a provider has the right to bill patients for a full unit of service. The reason for this is that not every outpatient treatment can be broken down into increments of 15 minutes.
To qualify for this type of service, treatment sessions and therapy must be limited to one-on-one care sessions, and the duration of therapy must last a minimum of eight minutes. During this time period, a therapist or service provider is not allowed to tend to other patients, and the therapist cannot “document” services for other patients during this period.
Instead, a therapist is required to interact only with the individual receiving services and not lose focus on the patient, because other individuals are present or require care. The therapist must remain focused on the patient and oversee the patient’s exercises and therapies by themselves.
A single session may be billed as more than a single unit. This process is quite simple. When Medicare looks over a claim, the total time of service minutes is divided by 15. If a minimum of eight minutes “remain” before the start of the next 15-minute interval, a provider can bill you for the next unit of services. If fewer than eight minutes are left before the next unit, your provider is not allowed to bill for the next unit.
What are units?
A single unit of service, as noted before, lasts anywhere from eight to 22 minutes. If a provider spends 23 to 37 minutes on a session, that provider can bill Medicare for two units of care. If services last from “38 to 52 minutes,” that provider has the right to bill you for three total units.
The rules for service-based units are slightly different. With service-based units, a therapist can bill only one unit of service for a single visit. The duration of a session has no impact on how many units a provider can bill. There are time-based codes for different services, and codes are different for different kinds of therapies.
A CPT code for manual electrical stimulation is 97032, while a CPT code for manual therapy is 97140.
Of course, it helps to know the difference between different types of units. How are time-based units different from service-based units? You must use a service-based unit for single service sessions, where a provider provides a single service, such as unattended electrical stimulation, the application of hot or cold packs, a physical therapy exam, or re-examination.
A service provider cannot bill more than one unit for these types of services, despite the amount of time spent on service delivery. However, time-based codes give a provider the right to bill several units in increments of 15 minutes. This is also referred to as direct therapy. These codes are used for “one-on-one” activities and procedures that require a therapist to be present the whole time.
Services that fall under this category include ultrasound, gait training, and therapeutic exercise. While each time code is equal to 15 minutes of therapy, your treatment times do not always fall into neat increments of 15 minutes. Let’s suppose that a provider provides a test for 10 minutes or an ultrasound for five minutes. Medicare has specific guidelines for this. To be billed for one unit, a service provider must provide a service for a minimum of eight minutes.
If seven or eight minutes are left, Medicare cannot refund you in full for a unit. There seems to be a lack of practitioners’ knowledge when it comes to Medicare’s 8 Minute Rule. As a result, mistakes are often made. Such mistakes can sometimes lead to underbilling. A mistake can also make it take longer to get a reimbursement.
Medicare’s 8 Minute Rule applies primarily to outpatient services. Physical therapy falls into this category. The 8 Minute Rule applies only to services in which a provider is with a patient and has a direct interaction with him or her. If you receive more than one service, Medicare will bill you based on the total number of minutes for each service.
However, if you receive care that lasts fewer than eight minutes, Medicare will not be billed for this service. Since 15 minutes equals one unit, a service lasting 22 minutes will be billed to Medicare. Medicare is billed for this service, since the total time spent on service is greater than eight minutes.
Hospital outpatient and emergency facilities, rehabilitation centers, and private practitioners exercise the 8 Minute Rule. Practitioners who follow the 8 Minute Rule typically provide both outpatient and inpatient services.
However, the 8 Minute Rule applies to more than just Medicare. It also applies to federally funded plans, such as TRICARE and Medicaid. The Civilian Health and Medical Program or CHAMPUS also falls into this category. Certain commercial plans may also utilize the 8 Minute Rule. Medicare requires that the 8 Minute Rule be used for in-person services and outpatient services, so providers do not have the option to use a different billing method.
Of course, it is important to remember that the 8 Minute Rule comes with many benefits. According to experts, the 8 Minute Rule specifies the smallest amount of time that’s required to bill Medicare for a service. This guideline makes certain that Medicare recipients receive a high quality of care and that providers are fairly compensated for providing that care.
If you want to utilize the 8 Minute Rule, it is important to know to which providers it applies. According to Cover Right, occupational and physical therapists, speech pathologists, and some other care professionals utilize the Medicare Minute Rule. Services administered by these specialists include neuromuscular reeducation, therapeutic exercises, and manual therapy. A physical therapist may fall under the 8 Minute Rule if they spend three minutes on manual therapy and five minutes on therapeutic exercises during a session.
You can add up time spent on different services in a session to satisfy the 8 Minute Rule requirement. It also helps to understand terminology that relates to the 8 Minute Rule. Billable time is one such example. Billable time refers to the time a professional spends, which can be charged after services are provided.
Medicare provides reimbursements to providers according to the minutes they spend providing care or medical services. Let’s define the services that fall under the 8 Minute Rule. Therapeutic exercises are some of the most well-known services provided by physical therapists. These are occupational or physical exercises that aim to improve one’s flexibility, endurance, range of motion, and strength.
Manual therapy is therapy in which occupational or physical therapists do exercises on your limbs or joints to restore functions or treat an existing manual impairment. Therapists also stretch muscles to facilitate manual functions.
With neuromuscular reeducation, you learn methods to restore manual function or “improve” existing manual function. You can also get modalities. These incorporate the use of equipment or adaptive devices to help ease pain or reduce inflammation. However, bear in mind that there may be limitations and calculations involved.
There is a method to calculate billable time and get the proper reimbursement. The first step is to determine for which services you can receive reimbursement under Medicare’s guidelines. You should also keep a record of how much time is spent on individual services. If you have received multiple services, you should add up the time for which you received services.
Non-billable activities should be excluded. Time spent on administrative tasks, the preparation of paperwork, and activities that do not require outpatient care should not be included. There is a cumulative calculation rule, which specifies that you cannot combine time for all activities. There are restrictions on some services when it comes to cumulative calculation.
4 Sources
MedigapCoverage has strict sourcing guidelines to ensure our content is accurate and current. We rely on peer-reviewed studies, academic research institutions, and medical associations. We strive to use primary sources and refrain from using tertiary references.
https://experience.care/blog/tips-medicare-8-minute-rule/.
https://coverright.com/blog/medicare-101/medicare-8-minute-rule/.