What is Substantial of a Time-Based CPT Code

April 29, 2019
Rick Gawenda

For those of us that treat Medicare beneficiaries for outpatient physical, occupational and/or speech-language pathology services, we all understand that the Medicare program utilizes what as come to be known as the “8-minute rule” when determining how many time-based units can be billed during an outpatient therapy visit. But what about non-Medicare insurance carriers that do not utilize the “8-minute rule”? How do we determine how much time of a time-based CPT code must be provided in order to bill that CPT code to an insurance carrier that does not follow the Medicare “8-minute rule”? In this article, I will explain Medicare’s “8-minute rule”, who it applies to (Medicare Advantage plans and state Medicaid programs?) and also explain how to bill non-Medicare insurance carriers who do not follow the “8-minute rule” when providing time-based interventions and procedures.

Lets begin with the “8-minute rule”! The Centers for Medicare and Medicaid Services (CMS) implemented the ‘8-minute rule” in calendar year 2000. The “8-minute rule” only applies to those CPT codes

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  1. I find that billing and coding language is often clouded within contracts. What are your recommendations when browsing through the contract language to decipher third party billing language and whether “8 min vs substantial portions” methodologies are being utilized?

    1. You need to read the contract carefully and know what you are looking for. You also need to read any online therapy policies the insurance carrier may or may have on their website.

  2. Do you have any suggestions on how to find these answers efficiently? Where will they be found? What language will they use? My frustration with this is that because the language is so convoluted and hard to decipher / hard to find that there seems to be “gray areas” where one practice/clinician will interpret it different than the next. I live in west Michigan- is there a resource that has the general billing rules for each insurance carrier? Who follows 8 min rule / MC guidelines and who follows substantial portions? Thanks for the help.

    1. They could be in your contract. They could be in an online policy. The insurance carrier could also be silent on the subject matter.

  3. So as another example, if I perform 20 minutes of ther ex with a patient and 5 minutes of manual treatment, what would Medicare billing look like? From the information given above, non-Medicare billing would be 1 Ther ex charge, correct?

    1. You are correct. For Medicare, you would bill 2 units total. You would bill either 2 units of 97110 or 1 unit 97110 and 1 unit 97140.

  4. Hello Rick, Question, the client is treated for 51 minutes and then the therapist writes note and cleans up. We are billing to private insurance. Can we bill 4 units of 97530? Thank you, Philip

  5. Sorry to potentially repeat Eric above. I have looked through the online Tricare West manual without success. Can you clarify if Tricare west follows the 8 min rule or Substantial portions?

  6. If a provider is silent on the topic of 8 minute rule vs. substantial, is it safe to assume you can follow the substial ruling for billing?

  7. If Medicare is a secondary payor and a commercial insurance who follows the AMA substantial portion methodology is primary, can I bill based on the AMA substantial portion methodology and still bill Medicare secondary?