A question I often receive is what CPT codes does the so called “8-minute rule” apply to? Does it apply to just the 15-minute time-based CPT codes or does it also apply to the 1-hour time-based CPT codes as well as the untimed, supervised modality CPT codes and untimed evaluation CPT codes?
The “8-minute rule” applies to all CPT codes
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Just to clarify (I’m sure you answered this in class as well), if I see a patient for 10 minutes of gait training and 10 minutes of evaluation for a total of 20 minutes, I would bill 1 unit of evaluation then ignore those minutes as it is untimed and bill 1 unit of gait because there are 10 minutes of a timed cpt?
In this scenario, you would bill 1 unit for the evaluation and 1 unit for the 10 minutes of gait training. I will also say an evaluation will probably take more than 10 minutes.
In regards to Ultrasound – a timed code – – for 2 units – @ 2 locations- – is it still 1unit of charge if 23 min and underground
Tis is only for Medicare patients only, correct. no commercial insurance follows this rule. for example, for non-medicare, if we did 10 min of EX, 10 min of Manual Therapy, and 10 min of ES-Attended, it would be 3 units that could be billed since all three modalities were preformed whereas Medicare only would allow us to be 2 units. I found something from the AMA in re. CPT 15-min rule and there was a note about billing the unit if you went half-way into the 15 min time.
You would have to check with the specific commercial insurance carrier to see if they follow the “8-minute rule”. You will be surprised that some do.
Does the 8 minute rule cross disciplines? For example- If a patient is seen by both a PT and an OT on the same day at the same facility, are the minutes counted together (to decide on the units to bill) or is it discipline specific? I can’t seem to find an example of this scenario on the CMS site…
It’s by discipline.
Do you apply the 8 minute rules for charging timed codes for Medicare Part A for hospital inpatient services?
In an inpatient setting under Medicare Part A, you are not paid via CPT codes, rather, via DRGs. If the patient changed from Part A to Part B, then you would bill CPT codes and all of Medicare’s documentation and billing rules and regulations for outpatient therapy would apply.
Thank you Rick. But just to clarify, at our facility, even though reimbursement comes from DRG’s, we account for our time and productivity via the same charge master that our OP area uses. Should we use the same rules (less than 8 minutes = no charge) for timed codes in the IP area?
CMS gives no guidance on IP billing since you are not paid via DRG’s. If the Medicare beneficiary were to switch from IP to outpatient, then all the Medicare rules, regulations, and billing would apply.
Rick, Can you provide some clarification as to how to allocate charges with regard to time spent for in -patient (Medicare Part A). If CMS does not provide guidance for In patient billing, where does this guidance come from?
CMS does not provide instructions or examples for true inpatient acute care therapy billing since you are paid via DRG’s.
I keep reading about being able to bill for an additional unit due to “mixed remainders.” What does this mean?
Also, if I have a payer that says they go by AMA’s guidelines (vs CMS) what does that mean? I didn’t think AMA had billing guidelines for converting minutes to units.
I will be publishing an article later this month on the billing differences between the “8-minute rule” and definition of substantial.
Hi Rick, did you publish this article? I’ve searched and can’t find anything. Thanks!
Yes. You are on this article.
I have a specific scenario regarding timed CPT codes. If a therapist sees a patient in an outpatient setting in the am for 25 minutes (therapeutic exercise) and then sees the same patient for another 25 minutes (therapeutic exercise) in the pm what is the correct charge? These are two separate appointments and two separate notes. Do you take into account the total minutes (50 and charge a total of 3 units)? Or do you charge each visit separately (2 units for each visit)? Does this change if it is a different therapist for each of the two appointments?
For the Medicare program, you would add up the 2 sessions to determine how many 15-minute time-based units you can bill. Read Section 20.2C of the link below where CMS states “When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed.” https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf
How does the 8 minute rule apply for a pediatric co-treatment with PT and OT (assuming they have Medicaid following the 8 minute rule)? For example, a patient comes late and is only seen for 18 minutes. PT and OT both charge for 9 minutes. Does the rule still apply per discipline or combined?
The “8-minute rule” applies to the total timed minutes of 15-minute codes done that date of service per discipline.
I am in acute care. Question re: documentation requirements for everyone. If my in/out time for a pt was 45 minutes and i billed 8 minutes for therapeutic exercises and 15 minutes for gait training what would my total treatment time be considering the time of the evaluation if the evaluation was 15 minutes?
Is there a difference between “total session time of 45 minutes” and “total treatment time?” If my eval was 15 minutes would i add 23 min (ther ex + gait) + 15 for eval = 38 min total treatment time?
In my note do I need to document “total session time” of 45 min OR “total treatment time” of 38 min?
In true acute care where you are paid via DRGH’s, the Medicare program does not give guidance on how time must be documented. If the Medicare beneficiary switches from inpatient status to outpatient (OP) status, then you would follow the OP rules and regulations for documentation of time.
Rick, I have tried to determine which commercial insurance companies require the 8 minute rule, but many of the customer service reps I have spoken with say that they are not sure or have not heard of the 8 minute rule (or rule of eights). Do you have a list of them in your Gold plan?
Unfortunately, there is no list due to the mass number of insurance carriers.
In the inpatient hospital setting is it appropriate and legal to bill for an evaluation (untimed code) and a treatment (timed code) within the same visit? We are being asked to bill for an evaluation and tag on 1 treatment unit for evaluations we do. Thank you!
Keep in mind that for a true inpatient, you do not submit CPT codes to insurance carriers on the claim form and are not paid via CPT codes. With that said, you can “bill” an evaluation and treatment the same visit if both were provided.
Hi Rick. In OP PT setting, if I did 20 min ther ex, 20 min manual, and 20 min ther act can I bill 2/2/2 units for non medicare?