The Medicare 8-Minute Rule Explained in 2 Minutes
The Medicare 8-Minute Rule is a way providers can charge for the services you receive. The rule matter to seniors on Medicare because errors can happen. These can result in issues such as delayed reimbursement or billing issues.
Chances are you’ll never be impacted. But, because many seniors have called the Association offices asking questions, we post the following. We’ll discuss how the Medicare 8-Minute Rule works and what you should know.
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What Is The Medicare 8-Minute Rule?
Starting April 1, 2020, the ‘8-minute rule’ applies to time-based Current Procedural Terminology (CPT) codes. These codes are used to bill Medicare for outpatient services.
The 8 minute rule allows therapists, usually rehabilitation therapists, to accurately determine the number of units they can bill for specific timed services. The rule generally applies to Medicare billing. That said some private insurers also use it.
An example is physical therapy. The rule allows the physical therapist to bill Medicare for ‘1 unit of service’ provided the length of service (treatment) is at least eight minutes. It has to be less than 22 minutes. Under the rule, units of service consist of 15 minutes each.
The rule applies to the following entities or individuals who provide in-person or outpatient services.
- Providers like private practices
- Skilled nursing facilities
- Rehabilitation facilities
- Home health agencies that provide therapy covered under Medicare Part B in the home of the beneficiary
- Hospital outpatient departments (including emergency)
Time-Based and Service Based Codes
The Medicare 8 minute rule is based on time-based service codes. Note that not all CPT codes are time-based. Some are service-based.
Here are some examples of time-based codes (used when billing Medicare).
- 97110 – therapeutic exercises
- 97140 – manual therapy
- 97035 – ultrasound
- 97530 – therapeutic services
- 97542 – Wheelchair management/propulsion training
Here are some service-based codes used for billing;
- 92506 – Speech/hearing evaluation
- 95833 – Manual muscle testing
- 97001/97002 – physical therapy evaluation/re-evaluation
- 97003/97004 – occupational therapy evaluation/re-evaluation
Does Medicare Advantage Follow the 8-Minute Rule?
No. This rule applies to Medicare Part B. Medicare Advantage (MA) plans (also known as Part C) do not have to follow the rule. MA or Part C plans have their own billing and payment rules.
Medicaid does use the same CPT codes, billing guidelines, and amount of time to calculate minutes from healthcare professionals.
This Is How The Rule Actually Works
Only to services where the healthcare practitioner actually has direct, in-person contact with the patient count. For example, billing time would not count.
Under terms of the rule, if the person provides more than one service, Medicare will be billed based on total timed minutes per discipline. If an individual service takes less than eight minutes, Medicare won’t be billed for it.
Medicare gets billed for services in 15-minute units. That said, if it takes say 20 minutes, Medicare will still be billed for one unit. That’s because the number of minutes falls between 8 and 22.
The chart shows the applicable number of units that Medicare can be billed. For example, If 2 units can be billed when the time spent falls between 23 and 37 minutes. If they take 38 to 52 minutes, the practitioner can charge for three units, and this pattern continues (in 15-minute intervals) beyond two-hour services (see chart).
Time Segments – Time Spent & Billable Units
- 8 minutes to 22 minutes = 1 unit
- 23 minutes to 37 minutes = 2 units
- 38 minutes to 52 minutes = 3 units
- 53 minutes to 67 minutes = 4 units
- 68 minutes to 82 minutes = 5 units
- 83 minutes to 97 minutes = 6 units
- 98 minutes to 112 minutes = 7 units
- 113 minutes to 127 minutes = 8 units
Some Additional Medicare Information Resources
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Written by Jesse Slome. Slome is one of the nation’s leading experts in Medicare insurance. He is founder and director of the American Association for Medicare Supplement Insurance as well as the American Association for Long-Term Care Insurance.