Medical billing can be overwhelming for physical therapists, especially for small practices where trained medical billers are unavailable. To get proper reimbursement for your services, it is essential to follow the billing guidelines. One such guideline or standard is the Medicare 8-minute rule.
Yet many billers misunderstand it, leading to lower payable amounts and even claim denials. This rule determines how outpatient therapists, including physical, occupational, and speech therapists, bill Medicare for time-based services.
If you find it difficult to bill your services, don’t worry. This detailed guide is all about the Medicare 8-minute rule. Here, we will break down what the 8-minute rule is, how it works, and how it applies in real-world scenarios. So, let’s start.
What is the 8-Minute Rule by Medicare?
The Medicare 8-minute rule, sometimes called the “8-minute therapy rule” in medical billing, is a billing standard provided by the Centers for Medicare and Medicaid Services (CMS).
This rule determines how outpatient therapy services are billed when the provided service falls under the time-based CPT codes. According to this rule, all therapists must spend at least 8 minutes in a one-on-one session with the patient. This one 8-minute session will be counted as one unit of service.
Many billers get confused here. Because each unit is for a 15-minute session, the 8-minute threshold allows billing even if the full 15 minutes are not reached. Yes, it is a bit confusing, but to clarify, let’s look at an example.
Suppose a therapist spends 10 minutes directing therapeutic exercises. He can bill one unit because it exceeds the minimum 8-minute mark.
An important thing to note here is that the Medicare 8-minute rule is used only for time-based codes. It cannot be used for untimed or service-based codes (like evaluations). So, if you want to use the 8-minute therapy rule correctly, you must have a good understanding of CPT codes.
How Does the Medicare 8-Minute Rule Work?
Let’s understand how you can practically use the Medicare 8-minute rule to bill for your services. Here’s a step-by-step breakdown of how it operates:
Identify Time-Based Codes
As a first step, try to pinpoint all the services in a session that are billed using time-based CPT codes. For example, in a single session, you can provide therapeutic exercises, which are billed using CPT 97110, and manual therapy, which is covered by CPT code 97140.
Track Time
Once you have identified the time-based services, you should track the exact minutes spent on each service. Please note that only face-to-face and skilled treatment will be counted here. Activities like charting or patient education outside direct care do not qualify.
Add All the Minutes
Now, sum the total minutes spent on all time-based services in the session.
Calculate Billable Units
To calculate the total billable units (units of 8-15 minutes), divide the total number of minutes that you calculated in the previous step by 15. If the remainder is 8 minutes or more, you can bill an extra unit. If it is less than 8, it does not count toward an additional unit.
Let’s do a quick calculation as an example:
If a therapist spends 25 minutes on time-based services:
- 25 ÷ 15 = 1 unit, with a remainder of 10 minutes.
- Since 10 is greater than 8, he can bill 2 units.
Now, you do not have to repeat all these calculations every time. To make things easier, you can use the following 8-minute rule Medicare chart:
| Service Time | No. of Units |
|---|---|
| 0-7 minutes | 0 unit |
| 8-22 minutes | 1 unit |
| 23-37 minutes | 2 units |
| 38-52 minutes | 3 units |
| 53-67 minutes | 4 units |
| 68-82 minutes | 5 units |
Scenarios Where the Medicare 8-Minute Rule is Applicable
It is always easy to understand complex things when we can relate to them in real life. So, let’s bring the Medicare 8-minute rule for physical therapy into focus with practical examples:
Scenario 1
John, a patient recovering from a shoulder injury, visits his physical therapist for a session that is necessary to improve his range of motion. The therapist decides to perform manual therapy, which is billed using the CPT code 97140, to help alleviate John’s muscle tightness. During the whole session, the physical therapist spends a total of 18 minutes on John’s shoulder.
Since the time spent falls within the 8–22-minute range, the therapist bills 1 unit for the service. If the session had been extended to 23 minutes, the therapist would have billed two units, as the additional 8 minutes would have met the threshold for another unit.
Scenario 2
Now, let’s look at the scenario where multiple timed services are performed.
Suppose a patient with chronic back pain goes to an outpatient practice for her physical therapy sessions. The sessions are designed to strengthen her core muscles and improve her posture.
The therapist begins the session with 12 minutes of therapeutic exercise (CPT 97110) to enhance her flexibility and strength. After this, the therapist dedicates 14 minutes to neuromuscular re-education (CPT 97112). This is done to help improve the coordination and balance of the patient.
The total time spent on these services amounts to 26 minutes. By dividing the total time by 15, the therapist determines that 1 unit can be billed, with a remainder of 11 minutes. Since the remainder exceeds 8 minutes, the therapist bills 2 units, typically assigning one unit to each service based on the time spent on each.
Scenario 3
Michael is a patient who has recently started experiencing problems with his gait. He visits a physical therapist for an evaluation and treatment session. Before providing any treatment, the therapist begins with a comprehensive physical therapy evaluation (CPT 97161), an untimed service. Without doing any calculations, he bills 1 unit of service for it.
After the evaluation, the therapist spent 10 minutes on gait training (CPT 97116). This will improve Michael’s walking patterns. Since the 10 minutes of gait training falls within the 8–22-minute range, the therapist bills 1 unit for this time-based service. In total, the therapist bills 1 unit for the evaluation and 1 unit for the gait training.
Medicare 8-Minute Rule vs. AMA’s Rule of Eights
Many people mix Medicare’s 8-minute rule with the Rule of Eights. Although both rules are used for the same purpose, they are a bit different.
We have already discussed that the 8-minute rule is a Medicare standard. On the other hand, the Rule of Eights, also known as the Midpoint rule, is a standard of the American Medical Association (AMA).
The Rule of Eights takes a different approach. Instead of adding the times for each service, it looks at each treatment unit separately. You cannot charge for a unit unless the one-on-one treatment lasts at least 8 minutes.
For instance, if you perform 8 minutes of therapeutic exercise and 8 minutes of manual therapy, you must bill two separate units. This means that you will list 1 unit of therapeutic exercise on one line and 1 unit of manual therapy on another line.
On the contrary, if you use the 8-minute rule, you have to add the times of both services and then divide by 15. For example, if you have 16 minutes from both services, you would divide by 15 to get 1 unit. You would have to choose just one unit to bill, either 97110 or 97140, but not both.
Wrapping Up
The 8-minute therapy rule directly impacts the revenue of a practice and the quality of patient care it provides. This rule allows you to bill the accurate amount for your services without any deductions. So, you need to use it properly.
With this guide, we believe you have all the necessary information to use the Medicare 8-minute rule in your billings. However, if you are having trouble receiving justified reimbursements or facing claim denials, our medical billing and coding services are the perfect solution. Connect with our billing experts at NeuraBill to discuss all the details.
