What Are Billing Units Physical Therapy in Medicare?

Physical therapy is considered one of the most essential elements of the health and medical industry. It also has a complex procedure when it comes to billing.

The billing units physical therapy uses have their own importance and are different from the regular billing processes.

The billing procedures and billing units physical therapy comprises comes under the regulation of the Centers for Medicare and Medicaid Services (CMS).

About 44 million people are enrolled under the banner of medicare and this population is expected to grow to approximately 79 million by the end of 2030. Now, this is actually an uber challenge faced by the system of catering to this huge population for their physical therapy billings by the medical practitioners.

This is where the 8 minute rule came into being. The Health Care Financing Administration (HCFA) stated that an 8 minute rule must become a mandatory beneficiary in the medicate bills, especially for patients of physical therapy.

The system will also bill other therapeutic services according to the 8 minute rule. The units will define how many times a particular service was provided to a patient.

What is the 8 minute rule billing units physical therapy uses?

What is the 8 minute rule billing units physical therapy uses

The 8 minute rule is the name given to the procedures that lead to the billing of all the physical therapy services provided under Medicare. The 8 minute rule particularly emphasizes on the therapeutic services that are in direct contact such as the services provided by the physician directly to the patient but they should last at least 8 minutes.

The CPT codes for time are further broken down into units which are further based upon different time intervals.

The 8 minute rule, if not understood correctly, can lead to errors in billing that can cause delays in reimbursements, forming an audit, or sometimes leading to a kind of under billing. This can occur because the services provided by physical therapists and the visits to the therapy center have different codes and they need to be well managed and well understood keeping in mind the 8 minute rule of billing units. The billing experts must bill the patients according to the rules derived by CMS. However, if any patient has any other insurance policy other than Medicare, then the same rules would not be applied to those bills unless any specification is made by the said insurance company.

Medicare and the 8 minute rule

According to the rules and regulations, the 8 minute rule specifically covers the direct contact service that is therapeutic in nature and is mainly based upon direct contact with the patient or a one-on-one visitation. Thus, a physical therapist is obligated under Medicare to give services to its patients that are a minimum of 8 minutes in order to receive reimbursements according to the CPT time-based codes determined by Medicare.

According to Medicare, the CPT codes are devised according to different intervals, and these codes define different kinds of procedures.

These units actually determine the times a service was utilized.

The 8 minute rule chart according to the Medicare

According to Medicare, the units which determine the therapeutic services depend upon the intervals of minutes.

An 8 minute rule chart always comes in handy while trying to understand the billable units more accurately, entirely depending upon the time which a therapist gives to the patient while providing them their services.

8 minute rule billing insurance

Every federal payer is supposed to do the billing according to the 8 minute rule. There are a few cases where different insurance companies willingly accept billing through Substantial Portion Methodology (SPM) but still, the 8 minute rule is considered a standard for measuring the timed services in physical therapy.

8 minute rule is used to bill the physical therapy services and the sources which are liable to follow are:

  • Medicare
  • Medicare Advantage programs
    • Pyramid Life
    • Medicare Plus Blue
    • Aetna Advantage Plans
    • Humana (advantage programs)
  • Medicaid
  • Different Federal Payers:
    • Blue Cross for Federal employees
    • Tricare (Armed Services)
    • Champus (veterans)
    • OWCP: Office of Worker’s Compensation Program, which is administered by ACS

CPT codes (Current Procedural Terminology)

CMS manual and 8 minute rule

Current procedural terminology codes (CPT-4) are the ones that usually render the services of physical therapists to be rendered further. These CPT codes are recorded in the documentation of the bills for the reimbursements of the physical therapists through third parties which also includes Medicare.

The American Medical Association (AMA) created these codes and this is the regulatory body that is supposed to maintain them as well.

Most of the codes used by the physical therapists are decried under the 97000 series for the services and treatments section titled “Physical Medicine and Rehabilitation.”

A physical therapist is not supposed to limit himself under this section because there are various other codes of CPT that describe the services and treatments which are provided by a physical therapist.

It is mandatory for the physical therapist to get familiar with these codes in the 97000 series as well as other codes as the service provider can bill for any code under the licensure laws of the state that legally renders his services.

A physical therapist must know the difference between payment policy and CPT coding clearly because it might be possible that a code is used by the physical therapist but a payer might not reimburse this code and make a claim.

CPT codes – Untimed and timed

These are two kinds of CPT codes that both bring reimbursements.

Untimed codes – The services based upon untimed codes are the ones that can see only one code to bill any service and the time that is spent while providing the services will not make any difference in the reimbursements. These services do not have to be direct contact or one-on-one contact for reimbursement.

Some of the untimed codes are

  • Hot/cold packs (97010)
  • Physical therapy evaluation (97163, 97162, and 97161) or the re-evaluation of (97164)
  • Medicare Non-wound (Unattended), G0283 Electrical Stimulation

Timed codes – The services based upon timed codes are the ones that can provide reasonable increments of as much as 15 minutes. The timed coded services must be provided in direct contact or one-to-one meetings.

A single unit of code 97110 in CPT represents a therapeutic exercise that can extend to 15 minutes during a session of physical therapy.

However, any other physical therapist might provide the same code of CPT of 97110 for a mere 10 minutes. The difference can result in the usage of multiple codes for different intervals of time used by different physical therapists at the same time.

So, according to the CPT codes – time-based, to have one unit of a service that can be billed, the physical therapist might provide service for at least 8 minutes. When this timing exceeds the time frame, the number of units medical providers spent while giving service are calculated together as the total time in treatment in the bill for ease and transparency.

CPT codes – time-based

The physical therapy time-based codes are based on the time that a physical therapist supposedly spends on a patient. According to the tale posted above, a therapist spends more than 8 minutes treating a patient, can bill it as a unit for that particular time, and so on.

Medicare stated that the number of timed units which are documented by a therapist in one day is paid to him after they are divided by 15. The reason behind this theory is that there can be units that are not more than 15 but more than 8 so that the therapist gets paid for one extra unit.

The 8 minute rule chart according to the Medicare

Here is a list of the medical services and procedures that you CPT time-based codes:

  • Gait training (97116)
  • Ultrasound (97035)
  • Therapeutic activities (97530)
  • Manual therapy (97140)
  • Therapeutic exercises (97110)
  • Neuromuscular re-education (97112)
  • Electrical stimulation (97032)
  • Iontophoresis (97033)

According to the CPT codes, if the time spent by the physical therapist exceeds the billing time, then he is allowed to bill an additional unit at the end of the day to compensate for the extra time.

CMS manual and 8 minute rule

CMS manual describes the 8 minute rule in detail and according to the manual, it is very effective when it comes to billing.

The manual states that because of this additional one unit, the therapists strive to pay more attention to the patients as the unit billing must be more than 8 minutes.

However, there are some exceptions where the treatment might take less than 8 minutes. In such situations, according to the manual, the therapist is allowed to bill two units at once for one session. This is because the sessions took less than 8 minutes and a therapist catered to more than one patient in the period of 15 minutes.

These kinds of exceptions are acceptable while billing and are termed according to the law.

Final thoughts

It is extremely important to understand the CPT codes for billing both timed and untimed ones. These codes are important while compiling the final bill keeping in mind the 8 minute rule and the billed units.

The 8 minute rule is a very effective way of billing as it helps the physicians as well as patients to get physical therapeutic procedures and services on time. It is complicated to calculate the timed and untimed codes but as per the rules and regulations physicians are obligated to use them.

The 8 minute rule is also beneficial for insurance companies and other third parties as this minimized the fraud and scam risk to a great extent.