Medicare constrains the number of units that can be billed in outpatient therapy based upon the number of minutes of therapy. Based upon the time that is spent in providing therapy services that are performed in “timed” code treatment, the number of units that can be billed are defined in the Medicare 8 minute rule. Medicare has additionally provided information in the Claims Processing Manual to describe the process of calculating units that can be billed and has provided multiple different scenarios as clarification. According to CMS guidance:
If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc. ……When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service ….. determines the number of timed units billed. ….. If any 15 minute timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes. This is correct because the total time is greater than the minimum time for one unit. The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes.
Looking at a table provides as easy way for the therapist to see the allowable number of units that can be billed based upon the direct 1:1 therapy codes.
Medicare Minutes - 8 Minute Rule
|TIME in MINUTES||UNITS|
If a therapy session contains 9 minutes of therapeutic exercise, 9 minutes of neuromuscular reeducation and 9 minutes of manual therapy for a total of 27 direct minutes, then per the Medicare 8 minute rule and the chart above, the provider can bill 2 units. Paraphrasing CMS guidance: therapists “shall select …… the appropriate CPT codes (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only… two one units are allowed.” (Keep in mind that any untime codes would also be billed, such as unattended electrical stimulation). What happens if this is not a Medicare patient? Is billing the same?
Many therapy providers elect to follow the Medicare rules for any number of reasons. However not all payors require that the number of billable timed codes be constrained by the Medicare 8 minute rule. The American Medical Association (AMA), the authors and owners of the CPT system has provided clarification for all time-based CPT codes. This information can be found in the AMA CPT manuals, and speaks to billing when the time has passed the mid-point. Therapy providers that are not using the Medicare 8 minute rule should ensure they are following the guidance contained in the AMA manual for the use of the timed codes.