To prevent fraud and abuse, Medicare employs certain guidelines and restrictions. One of these regulations is the 8-minute rule. This rule maintains that medical practitioners must care for patients for 8 minutes or more to be reimbursed by Medicare. Some medical practitioners may not be aware of this rule. As a result, they may bill Medicare in error.
What Is the 8-minute rule for Medicare?
The Medicare 8-minute rule is a billing guideline for therapy providers that determines how much time the provider must spend caring for a patient before their service is billable to Medicare. The 8-minute rule defines a unit of service as 15 minutes of care. A therapist is unable to submit a claim for a unit of service unless the treatment lasts at least 8 minutes.
Does the 8-minute Rule Apply to All Medical Services?
The 8-minute rule is designed for outpatient therapy services that are time-based, such as physical therapy procedures. The rule, which was officially put in place in April 2000, applies to specific Current Procedural Terminology (CPT) codes—the codes that providers enter on Medicare claim forms to identify the exact medical services that they performed.
The 8-minute rule only governs in-person services. Additionally, the provider must have direct contact with the person they are treating.
How Do Service Providers Apply the 8-minute Rule as They Bill Medicare?
As a physical therapist provides care, they bill their services incrementally based on 15-minute treatment units. If they treat a patient for fewer than eight minutes, the provider is unable to bill Medicare for the services. Still, there may be instances when they see a patient for varying amounts of time. If they see a patient for 17 minutes, how should they bill Medicare?
The 8-minute rule mandates that they spend at least 8 minutes with a patient before they are allowed to bill Medicare for one 15-minute increment. If the patient receives care for 17 minutes, the provider can still only bill for one 15-minute increment. Before they can bill for two 15-minute units, they must spend at least 15 minutes (for the first unit) and an additional 8 minutes (for the second unit) with the patient. Thus, 23 minutes is the least amount of time that can be spent with the patient before billing Medicare for two 15-minute units of service.
Based on the 8-minute rule, the time requirements for billable units are:
- 1 unit = 8 to 22 minutes of care
- 2 units = 23 to 37 minutes of care
- 3 units = 38 to 52 minutes of care
- 4 units = 53 to 67 minutes of care
- 5 units = 68 to 82 minutes of care
- 6 units = 83 to 97 minutes of care
- 7 units = 98 to 112 minutes of care
- 8 units = 113 to 127 minutes of care
Which Providers Use the 8-Minute Rule to Bill Medicare?
The 8-minute rule applies to the following providers:
- Skilled nursing facilities
- Outpatient departments in hospitals
- Rehab facilities
- Private practices
- Home health providers that offer therapy at the patient’s home
Is the 8-Minute Rule Only for Medicare?
The 8-minute rule is used by insurance plans that are federally funded. As a result, in addition to Medicare, the rule applies to:
- Medicaid: Medicaid is a state-governed insurance plan for people with a low income.
- Civilian Health and Medical Program of the Uniformed Services (CHAMPUS): CHAMPUS is a health program for members of the military and their dependents.
- TRICARE for Life (TFL): TRICARE is insurance for military retirees and their dependents.
In addition to federally funded insurers, several commercial insurance plans adhere to the 8-minute rule. Nevertheless, private insurance companies are not forced to operate by the rule’s restrictions.
Examples of Billing With the 8-Minute Rule
Here are a few examples where the 8-minute rule would apply:
- Example 1:Mr. Green visited the office of his physical therapist. There, his therapist performed an ultrasound that took 12 minutes to complete. Additionally, the practitioner provided 16 minutes of manual therapy and 35 minutes of exercise. The total amount of time spent serving Mr. Green was 63 minutes. Thus, the therapist can bill Medicare for four units of service since the minutes of care were between 53 and 67 minutes.
- Example 2:Mrs. Smith received 30 minutes of manual therapy. During the same visit, her physical therapist took nine minutes to answer her questions. Moreover, the therapist assessed her condition for 11 minutes. The total time spent on Mrs. Smith’s care during her visit was 50 minutes, which is between 38 and 52 minutes. As a result, based on the 8-minute rule, her therapist would submit a claim to Medicare for three units of care.
Why Is it Important for Providers to Understand the 8-minute Rule?
Sometimes, providers may not be fully aware of all the services that should be included when submitting units of service to Medicare. Consequently, practitioners may not include the time that they spend performing certain services, such as assessing the patient’s condition. A lack of understanding concerning the range of procedures that should be billed may result in Medicare being under or over-billed.