You know the old saying, “time is money” but when it comes to billing outpatient therapy services, not all time is created equal. Yes, I’m talking about the dreaded Medicare 8-Minute Rule. At this point, you’re probably ready to click on to the next article, thankful that your EMR software does all the thinking, I mean, time calculation for you. But if you don’t know the basics how do you know if your EMR is applying the minute rules correctly based on the patient’s insurance? This mistake can potentially be costing you money and leave you at risk if you are audited. The excuse “my EMR made me do it” isn’t going to save you. In this article, we are going to give you a crash course on the relationship between the American Medical Association’s Current Procedural Terminology (CPT) codes and the minutes of clinical services provided. You will learn how rehab therapists use the Medicare 8 Minute Rule to determine what to bill Medicare for therapy services provided for a particular date of service.
CPT Code Definitions
Physical therapy providers select procedure codes to charge for clinical services delivered during a patient visit. Each code has an operational definition that describes the services provided. Some codes also reference the type(s) of clinicians qualified to deliver the service and/or the typical amount of time needed to deliver service.
“Timed” CPT Codes
CPT codes with a unit of time in their definition (e.g. 15 minutes) are classified as time-based (or “timed”) codes. “Timed” codes commonly used to bill for therapy services include, but are not limited to:
- 97110- Therapeutic exercise
- 97112- Neuromuscular re-education
- 97116- Gait training
- 97140- Manual Therapy
- 97530- Therapeutic activity
- 97532- Cognitive skills development
An individual qualified provider may bill multiple units of a “timed” code based on the amount of time spent delivering one-on-one services and any interpretative guidance provided by the payer.
“Untimed” CPT Codes
CPT codes without a unit of time in their definition are classified as service-based (or “untimed”) codes. “Untimed” codes commonly used to bill for therapy services include, but are not limited to:
- 97010- Hot/Cold Pack
- 97012- Mechanical traction
- 97016- Vasopneumatic devices
- 92506- Evaluation of speech, language, voice, communication, and/or auditory processing disorder; individual
- 92522- Evaluation of speech sound production
An individual qualified provider may bill a maximum of 1 unit of an “untimed” code no matter how long it takes to deliver the service.
PT and OT Evaluation and Re-Evaluation Codes
On January 1, 2017, the Centers for Medicare and Medicaid Services adopted new evaluation and re-evolution codes for physical therapy (PT) and occupational therapy (OT). The operational definitions of these codes include a “typical” amount of time; however, this information is used for guidance only. The new codes remain classified as “untimed” codes and follow the same rule as described previously.
- 97161- PT evaluation- low complexity
- 97162- PT evaluation- moderate complexity
- 97163- PT evaluation- high complexity
- 97164- PT re-evaluation
- 97165- OT evaluation- low complexity
- 97166- OT evaluation- moderate complexity
- 97167- OT evaluation- high complexity
- 97168- OT re-evaluation
Minutes of Service and Minute Rules
The total minutes of one-on-one time-based services dictate how many units a “timed” code(s) a qualified provider may bill.
Payers may have guidance regarding 1) who must provide the services (e.g. PT, PTA, OT, COTA, SLP etc.) and 2) the translation of minutes into units for time codes (i.e., a “minute rule”).
Type of Minutes for Time Codes
Hands-on Treatment Minutes are the number of minutes a qualified provider spent one-on-one providing intervention to the patient during the visit.
Patient Assessment/Management Minutes are the number of minutes a qualified provider spent during the visit performing one or more of the following activities:
- Assessing the patient’s progress, readiness for and response to the intervention applied.
- Education and/or communicating with the patient, or with caregivers/other providers while in the patient’s presence, and the intervention applied.
- Completing clinical documentation in the patient’s presence about the interventions provided
Types of Minutes for Untimed Codes
Direct Contact Minutes for Untimed codes are the number of minutes a qualified provider spent during the visit performing the evaluation service or interventions billed with “untimed” codes. These minutes include patient assessment and management during the application of the “untimed” intervention.
Indirect Contact Minutes for Untimed Codes are the number of minutes a qualified provider spent during the visit preparing the patient and necessary equipment prior to, as well as clean up after, application of “untimed” interventions.
Minute Rules for Timed Codes: The Medicare 8-Minute Rule
CMS uses the Medicare 8-Minute Rule as an algorithm for billing timed codes. Other payers also may use this rule. The Medicare 8-Minute Rule uses the following ranges of minutes to determine how many units of “timed” codes may be billed for a therapy visit:
- 1 unit: ≥ 8 minutes to < 23 minutes
- 2 units: ≥ 23 minutes to < 38 minutes
- 3 units: ≥ 38 minutes to < 53 minutes
- 4 units: ≥ 53 minutes to < 68 minutes
- 5 units: ≥ 68 minutes to < 83 minutes
- 6 units: ≥ 83 minutes to < 98 minutes
- 7 units: ≥ 98 minutes to <113 minutes
For time-based codes, you must provide direct treatment for at least eight minutes in order to receive reimbursement from Medicare. When calculating the number of billable units for a particular date of service, Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one or more unit; if seven or fewer minutes remain, you cannot bill for an additional unit.
Many times, however, when you divide the total timed minutes by 15, you get remaining minutes that include minutes from more than one service provided. For example, you might have 6 leftover minutes of therapeutic exercise and 2 minutes leftover minutes of manual therapy. Individually, neither of these remainders meets the 8 minute requirement, but when combined, they total 8 minutes- and per Medicare billing guidelines, that means you can bill one unit of the service with the greatest time total (in this example, would be therapeutic exercise.)
AMA Guidance on Timed-Based Codes
The main difference between Medicare’s 8-Minute Rule and the AMA’s version is how one handles the mixed remainders. Per AMA Time guidelines, you cannot use the cumulative total of your remaining minutes to justify billing additional units. Basically, if your left over minutes results from a combination of services, you cannot bill for any of those remainders unless one of them totals at least eight minutes. So in the example above, you could not bill for an additional units, of Therapeutic Exercise or Manual Therapy because neither meets the 8-minute minimum. You may, however, bill one unit of service for at least 8-minutes of each unique service. Where the Medicare rule and the AMA guidance are identical, if you are providing only one service, you must get to 23 minutes before you bill for the second unit. For example, if you performed 9-minutes of Therapeutic Activities and 10-minutes of Manual Therapy, you would bill one unit each of 97530 and 97140 even though the total is 19 minutes. But, if you performed 19 minutes of Therapeutic Exercises, you would bill only unit of 97110.
8-Minute Rules in RevFlow
We get it. Minute rules are tricky and if you’re not mathematically inclined that can be darn right scary! So if you want to ensure you are applying the correct minute rule to the correct payer, and billing your time accurately, make sure you’re using an EMR that was built specifically for outpatient rehabilitation and has built-in 8-Minute Rule functionality. RevFlow allows you assign the correct minute rule to each of your payers and applies overbilling and under-billing alerts. This, plus our other claim scrubbing technology ensure your claims go out cleaner and you get paid faster.