Understanding the Medicare’s 8 Minute Rule and Its Consequences

The 8 minute rule is a term specified for the rules and regulations designated by Medicare to prevent abuse, wastage, and fraud. It is not a known phrase and many of you might be intrigued to find out what is meant by the 8 minute rule.

In simple words, medical health practitioners are instructed to treat their patients for at least 8 minutes in order to receive a reimbursement in return from Medicare.

This rule is actually devised by Medicare.

Let’s have a look in great length at what is meant by the 8 minute rule.

What is the 8 minute rule by Medicare?

Medicare and Medicaid, both have given physical therapy guidelines that include a section called 8 minutes rule. This is the section which defines that how much time is necessary to be given to a patient for you to receive a medical reimbursement in return.

The eight-minute rule means that the medical practitioner is liable to spend eight minutes with a patient in order to bill at least one unit of “15 minutes”.

Medicare physical therapy works on the billing of 15 units. You need to complete each unit in order to get rewarded in return. Interestingly, if you spend 16 minutes instead of 15 minutes even then you will be billed for one unit only. So, an 8 minute rule was devised for the medical practitioners that if they spend 23 minutes that is 15+8 minutes with a patient they can claim two units instead of one.

What is the 8 minute rule by Medicare

How does the 8 minute rule work?

The 8 minute rule is a strictly time-based code for CPT which is devised for physical and manual therapy usage only. The 8 minute rule falls under the outpatient therapy marked by Medicare part B.

As the 8 minute rule describes that Medicare reimbursement is received as a unit if the physician spends 8 minutes with the patient, therefore it becomes tricky to differentiate the 8 minute rule from the standard 15 minute unit.

The “rule of eights”, which is also known as the billing units are generally based upon the 15-minute increment endorsed by Medicare as a standard to be spent with the patient. Therefore, it is compulsory under Medicare part B to complete the eight minutes with the patient in order to be paid for the 15 minutes unit payment.

For instance, if a physician has completed 17 minutes of a patient’s treatment, then Medicare will supposedly bill him for 1 unit of 15 minutes, however, if he completes 23 minutes of treatment then Medicare will bill the physician for two units of Medicare reimbursement. But just to remember, the bill will be charged for 2 units, regardless if the physician worked for 24 minutes or 30 minutes treating the patient.

Medicare codes for current procedural terminology (CPT)

CPT codes are meant to be the medical codes that are created to describe the services and procedures which are performed by the medical health providers and the insurance companies and the billing agencies calculate them to come up with a final result. These current procedural terminology codes (CPT) were created in the year 1966 by the American medical association and are considered a standard for procedural billing and reporting.

The codes are said to consist of five unique characters and are divided into three different categories.

The first category is about procedures and services

The second category is about the performance of the management

The third category is about the experimental and emerging procedures and services.

All of these above-mentioned categories are very vast in terms of the medical services that they code. Therefore, all of these categories are further divided into sections.

How does the 8 minute rule work

The first category comprises:

  • Anesthesia (codes 01000-01999)
  • Management and evaluation services (codes 99201-99499)
  • Radiology (codes 70010-79999)
  • Surgery (codes 10021-69990)
  • Medical procedures and services (codes 90281-99607)
  • Pathology (codes 80047-89298)

The second category contains:

  • Patient management (codes 0500F-0584F)
  • Composite measures (codes 0001F-0015F)
  • Patient history (codes 1000F-1505F)
  • Diagnostics (codes 3006F-03776F)
  • Physical exams (codes 2000F-2060F)
  • Patient safety (codes 6005F-6150F)
  • Preventive intervention and therapy (codes 4000F-4563F)
  • Non-Measure code numbers (codes 9001F-9007F)
  • Structural measures (codes 7010F-7025F)

The codes in the third category are all temporary and comprise four numbers only. They are followed by the capital letter “T”.

 The codes for physical therapy are further divided into time-based codes and service-based codes.

Time-based (CPT) codes

The time-based codes for CPT are:

  • Manual therapy: 97140
  • Therapeutic Exercise: 97110
  • Neuromuscular Re-education: 97112
  • Therapeutic Activities: 97530
  • Gait Training: 97116
  • Iontophoresis: 97033
  • Ultrasound: 97035
  • Manual Electrical Stimulation: 97032

Service-based (CPT) codes

The service-based codes for CPT are:

  • Physical Therapy Evaluations: 97161, 97162, 97163
  • Unattended Electrical Stimulation: 97014
  • Hot/cold packs: 97010

Difference between time-based codes and service-based codes

The time-based codes are different and you might be thinking about how time-based codes can be applied to an eight minute ruling of Medicare? Well, first of all, the eight minute rule works perfectly for the minimal services such as the cold compresses or performing brief examinations. These services are definitely not time-based, meaning that it is not necessary that they are finished within the timeframe of 15 or 23 minutes therefore they are billed differently.

Time-based codes make the billing procedures tricky. They can be used only for the “constant attendance procedures” which means one-on-one.

Difference between time-based codes and service-based codes

For example, a physician spends 25 minutes in taking in initially examining a patient. During this time, the physician and his accompanying staff ask several questions to the patients and answer their queries of the patient as well, check the infected spot, etc. For instance, let’s say that the physician took about 20 minutes to perform a physical therapy treatment on a patient in a one-on-one scenario.

So technically, it will be considered that the physician spent 45 minutes on the patient which is equal to three units of Medicare billing. But, here is the tricky part, the first 25 minutes will be counted as one unit as the physician was not present in the room for the whole initial time and was not performing an undivided procedure. Therefore, the physician is liable to get paid for two units only instead of three.

Remainders of 8 minute rule billing

When you are calculating a bill according to an eight minute rule then you are bound to get a remainder of several minutes in the form of multiple procedures and services.

For instance, if a physician has performed a medical procedure of 17 minutes on a patient and additional 21 minutes on the same person in the form of manual therapy then he will be charged one unit for those bills since both the separate treatment practices did not pass the eight minute mandate to be put into the next unit of billing. However, the minutes which are the remainder of the physical exercise and the manual therapy will be combined together and will be forwarded to the next billing unit under the eight minute rule.

According to the guidelines of Medicare in such cases, the physician is allowed to be billed for three separate units.

Does the eight minute rule apply to insurance?

No, it is not necessary that the eight minute rule gets applied to insurance. As per the definition, the 8 minute rule is said to be applied to Medicaid, Medicare, CHAMPUS, and TRICARE. The private insurance companies can select to be operated via the same guidelines as the Medicare but there is no rule or a mandate that they have to.

The Medicare beneficiaries who are said to be enrolled in the private Medicare plans also known as the Medicare advantage might also have different billing styles and standards depending upon the billing plan they select to be used.

Difference between the AMA 8 minute rule and the rule of eight

The rule of eights is often referred to as AMA 8 minute rule. This is done in the CPT manual of the codes. The CPT rules are said to be slightly different from the CMS rules applied under Medicare and Medicaid.

Even though the general concept of billing remains the same, meaning, the billing is according to the 15 minutes billing unit and the eight minutes extra of the service are counted as another 15 minutes unit. But, most of the time, these units are not combined. That is, each 15-minute unit of service is treated as a separate unit and is entitled to medical reimbursement separately. There are no mixed remainders in the end.

Difference between the AMA 8 minute rule and the rule of eights

On the other hand, the AMA code means that if a physician has performed a physical therapy procedure or service for about 16 minutes and another separate physical therapy service for 22 minutes then he will be billed for two units only and the extra minute of the 16 minute service and the seven minutes extra in the 22 minutes service will not be converted into a third separate unit like the CPT codes. At times the AMA timed codes are often used by other insurers instead of the CMS timed codes.

How should we avoid the 8 minute rule mistakes?

It is very easy to make mistakes when compiling a medical bill having codes of eight minute rule. It is very important to get professional help to make a bill or calculate the total. As a layman, you are bound to make mistakes if you are not fully aware of the technical aspects of the 8 minute rule.

The best way to avoid making mistakes while working with the eight minute rule is to use electronic calculators or billing programs and apart from this, it is equally important to have the exact insurance information of the patient so that you don’t end up making mistakes in the final bill or mess up the eight minute rule.

Final thoughts

Eight minute rule is a tricky rule which was derived for the betterment of the patient and the physicians by Medicare. Eight minute rule assists the physicians and gives them a small window to charge the medical reimbursement from Medicare according to their time and expertise. It is very important to use this rule effectively and efficiently with the right kind of codes for the time and the services provided by the physician.

Eight minute rule is often termed by the medical practitioners as the unit which is “bill-worthy”. This rule prevents wastage, double billing, or abuse of power by keeping strict regulations and rules for the recording of medical billings and payments.