What is Substantial of a Time-Based CPT Code

August 29, 2016
Rick Gawenda

A question I often receive is how much time of a time-based CPT code must I provide in order to bill that CPT code to a private insurance carrier that does not follow Medicare’s “8-minute rule” for billing purposes? The majority of CPT codes billed by physical and occupational therapy that are time-based are timed in 15-minute increments. Speech-language pathologists (SLPs) have very few time-based CPT codes. SLPs do have 4 CPT codes that are timed in 1-hour increments, 1 that is a 30-minute code (92608) and one that is a 15-minute time-based code (92627). This is not an all inclusive list of time-based CPT codes that are applicable to SLPs.

So lets answer the question. In order to bill a time-based CPT code to an insurance carrier that does not follow Medicare’s “8-minute rule”, the provider must spend

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  1. Using the AMA definition of attaining mid point and counting units, would you continue to have to reach each “whole” 15 min unit before beginning to attain midpoint of the next unit? The examaple above shows 2 units as reaching 15 mins then 8 additional mins for 23 mins. To acheived 3 units, would one need to reach 30 mins plus 8 mins? 45 mins plus 8 mins, etc…

    1. To bill 3 units of the same CPT code for an insurance carrier not following the “8-minute rule” you would have to provide that service for 38 minutes. 30 minutes would be 2 units and then 8 minutes is past midpoint of 15 for the third unit.

  2. Thank you for that information. To further clarify: (For Ins not following 8 min rule)
    If you were billing units of different CPT codes, would you have to only meet the 8 min mid point with each unit? For example: Ther Ex x 14 mins, Gait x 9 mins, Manual x 8 mins. Would this be 3 units at 31 mins?

  3. I’m seeing a trend esp with the marketing/business type PT programs pushing private practices to MAXIMIZE units during the session. For example, the expectation is 4 units in a 32 min session (4 separate CPT codes with 8 min duration) or an Evaluation + 5 additional CPT codes for an hour evaluation. This expectation is without the use of PT techs or modality use. The particular insurance companies don’t have restrictions on the units in these cases either. So, it’s not illegal and following the AMA guidelines with the substantial portion of a time-based CPT.
    But, if this is always the expectation from these facilities for their PTs, is this best practice? Are there any other concerns to be addressed aside from the possibility of the patient getting a large bill with a deductible?

    1. It’s up to each individual therapist to determine the needs of their patients and to provide those services. No insurance company would expect to see 4 15-minute time-based units billed when 8-minutes of each (total of 32 minutes) was provided on a consistent basis.